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FiSKE  Fund  Prize  Dissertation.       No.  LIX. 


SURGICAL  LESSONS 

OF  THE 

GREAT  WAR 


MOTTO: 

"  Pecowsic  " 


BY 

ALLEN  G.  RICE,  M.  D., 

Springfield,  Mass. 


PROVIDENCE : 

E.  A.  Johnson  &  Co., 

Printers. 


npHE  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting 
of  the  Rhode  Island  Medical  Society,  held  at  Pro\"i- 
dence,  June  3,  1920,  announced  that  they  had  awarded  a 
premium  of  two  hundred  dollars  to  an  essay  on  "  Surgical 
Lessons  of  the  Great  War  ",  bearing  the  motto  : 

"Pecowsic" 

The  author  was  found  to  be  Allen  G.  Rice,  M.D.,  of 
Springfield,  Mass. 

John  M.  Peters,  M.D., 

Providence,  R.  f. 

J.  E.  Mov/RY,  M.D., 

Providence,  R.  I. 

Herbert  Terry,  M.D., 

Providence,  R.  I. 

Trustees 

Halsey  DeWolf,  M.D., 
Providence,  R.  I. 

Secretary  for  tJte  Trustees 


SURGICAL  LESSONS  OF  THE 
GREAT  WAR 

Early  in  1914  the  Medical  Corps  of  every 
European  army  was  serenely  confident  of  its 
ability  to  deal  most  competently  with  battle  casu- 
alties, and  rightly  so.  Through  actual  experience 
and  keen  observation  in  the  Russo-Japanese, 
Boer,  and  Balkan  Wars  the  effect  of  missiles  on 
human  tissues  was  well  known  and  understood. 
The  character  of  war  wounds  and  their  treat- 
ment had  been  thoroughly  studied  and  completely 
mastered.  Advances  in  surgical  knowledge  and 
skill  had  not  only  made  possible  the  prevention 
of  infection  with  its  consequent  delayed  healing, 
disfigurement,  and  mortality,  but  had  also  so 
perfected  operative  technique  that  regions  of 
the  body  previously  deemed  inaccessible  could  be 
entered  with  impunity.  New  devices,  compact  and 
portable,  made  it  feasible  to  operate  aseptically 
in  the  open  field  far  from  established  hospitals. 
The  organization  and  training  of  the  Medical 
Corps  had  been  brought  to  a  degree  of  perfec- 
tion never  before  equalled.  Transportation 
facilities  for  the  wounded,  especially  the  motor 
ambulance,  were  so  efficient,  rapid,  and  elastic 
that  it  was  felt  unlimited  casualties  could  be 
promptly  handled  without  confusion  or  conges- 
tion. 

In  the  first  weeks  of  the  great  war  the  Medi- 
cal   Departments     functioned    smoothly.      The 


character  of  the  wounds,  for  the  most  part  due 
to  small,  sharp  pointed,  high  velocity  bullets, 
were  much  as  expected.  First  aid  aseptic  dres- 
sings held  off  infection  surprisingly  well;  as  low 
as  20  per  cent  of  the  wounds  became  infected. 
For  the  most  part  casualties  were  rapidly  evac- 
uated to  the  rear,  and  not  until  they  reached  base 
hospitals  were  they  subjected,  except  for  dire 
emergencies,  to  operative  procedures.  Even 
those  operated  at  the  front  were,  according  to 
prearranged  program,  sent  comfortably  to  the 
rear  at  the  earliest  possible  moment. 

With  the  definite  check  of  the  German  ad- 
vance, however,  and  the  resultant  dead-lock  from 
Switzerland  to  the  sea,  the  character  of  warfare 
was  vastly  changed.  Open  fighting,  swift 
maneuvering,  and  frequent  change  of  positions 
gave  way  to  the  fixed  routine  of  immobile  trench 
conflict.  The  rifle  and  bayonet  gave  way  to  artil- 
lery and  bombs ;  the  free  open  life  in  the  field 
was  bartered  away  for  a  cramped  and  crowded 
existence  in  and  under  the  earth.  The  whole 
scheme  of  warfare  had  to  be  radically  changed 
to  meet  unforeseen  conditions ;  every  military 
department  had  to  be  reorganized  and  to  a  large 
extent  re-equipped  with  new  devices  to  cope 
with  unsuspected  difficulties.  Many  well  tried 
methods  that  had  withstood  the  test  of  previous 
wars  proved  to  be  utterly  worthless  and  had  to 
be  ruthlessly  scrapped.  Probably  no  department 
of  the  army  was  harder  hit  than  the  medical ; 
for  the  great  principle  on  which  its  work  was 
primarily  based  was  proved  in  a  few  weeks  to 


be  nojE  only  useless,  but  to  some  extent  even 
harmful,  when  applied  to  conditions  incident  to 
trench  warfare.    Asepsis  fell  down. 

Infected  Wounds. 

In  direct  contrast  to  the  wounds  early  in  the 
war,  those  received  in  the  trenches  developed 
infection  almost  universally.  That  such  was  the 
rule  in  spite  of  painstaking  aseptic  technique 
from  the  moment  the  soldier's  sterile  first  aid 
dressing  was  applied  immediately  after  the 
wound  was  inflicted,  was  such  a  staggering  blow 
that  surgeons  were  loathe  to  believe  that  the 
principle  was  at  fault.  Unjust  criticism  was 
showered  on  the  front  line  dressers  who  were 
accused  of  breaks  in  technique.  But  as  time 
went  on  and  infection  of  wounds  continued  rife, 
the  unavoidable  conclusion  was  accepted.  That 
the  Medical  Corps  did  not  become  immediately 
and  utterly  demoralized  when  its  sheet  anchor 
gave  way  bespeaks  the  character  and  ability  of 
its  personnel.  True  to  its  traditions  the  medical 
profession  met  the  problem  and  conquered. 

The  causes  of  infection  were  not  hard  to  de- 
termine. The  preponderance  of  artillery  of 
large  calibre  using  high  explosive  shells  changed 
entirely  the  character  of  the  wounds.  Instead 
of  the  small,  clean  cut,  punctured  rifle  bullet 
wound  that  not  infrequently  simply  penetrated 
tissue,  there  presented  for  treatment  savagely 
lacerated  wounds  of  large  extent  generally  con- 
cealing in  their  depths  jagged  pieces  of  missile 
and  bits  of  clothing.     All  the  wounds  resembled 


the  torn  and  gaping  wounds  of  exit  made  by 
rifle  bullets  that  encountered  bone  or  that  were 
inflicted  within  the  range  when  the  bullet's  ex- 
plosive effect  was  paramount.  Furthermore  the 
destruction  of  tissue  from  high  explosives  ex- 
tended far  beyond  the  visible  limits  of  the  wound 
that  often  had  no  exit.  Muscle  and  fascia  under 
normal  looking  skin  surrounding  the  wound  was 
bruised,  battered,  even  dead,  robbed  of  all  power 
of  natural  resistance.  Thus  the  character  of  the 
wounds,  large  and  lacerated,  harboring  foreign 
bodies,  and  surrounded  by  an  area  of  devitalized 
tissue,  was  an  invitation  to  infection  that  was 
quickly  accepted. 

The  mode  of  living  imposed  by  trench  con- 
flict but  further  encouraged  infection.  Soldiers 
lived  below  the  surface  of  the  earth  under 
crowded,  unsanitary  conditions.  The  trenches 
themselves  were  always  wet,  frequently  mere 
mud  holes.  For  hours  at  a  time  the  men  were 
drenched  and  cold  which  led  to  universal  respira- 
tory infections.  The  filthy  dug-outs  swarmed 
with  vermin  that  preyed  on  the  men  and  inocu- 
lated them  with  debilitating  diseases.  Bodily 
cleanliness  and  frequent  changes  of  clothing 
were  impossible.  Skin  and  apparel  carried  into 
wounds  were  grossly  infected  with  many  va- 
rieties of  bacteria.  Every  aspect  of  the  existence 
endured  in  the  trenches  led  directly  or  indirectly 
to  debilitation,  sapped  vitality,  and  lowered  na- 
tural resistance  to  infection. 

Evacuation  of  casualties  from  the  front  line 
was   exceedingly   difficult.      Not   only   were   the 


trenches  themselves  actively  bombarded  but  the 
entire  back  areas,  especially  lines  of  communica- 
tion were  subjected  to  frequent,  regular,  and 
devastating  fire.  For  the  most  part,  therefore, 
the  wounded  had  to  be  moved  at  night.  It  was 
not  at  all  unusual  for  the  wounded  to  lie.  for 
hours,  frequently  even  for  days,  where  they  fell, 
wet  and  cold,  without  proper  treatment.  The 
first  stage  of  the  journey  to  the  rear  had  to  be 
taken  in  men-borne  stretchers,  slowly,  over  un- 
even and  precarious  paths,  through  winding 
trenches,  time  consuming  trips  that  unmercifully 
jolted  and  tortured  shattered  bodies  beyond  en- 
durance. Pain,  cold,  hunger,  and  thirst  increased 
every  hour ;  and  surreptitiously  infection  ripened 
and  spread  with  each  minute's  delay.  On  the 
other  hand  once  casualties  had  been  brought  to 
areas  of  comparative  safety  they  were  subjected 
to  repeated  transfers  from  hospital  to  hospital 
before  reaching  their  final  station.  The  move- 
ment was  ever  toward  the  home  area  on  the 
conviction  that  prompt  removal  of  the  wounded 
to  home  surroundings  was  in  itself  a  powerful 
psychological  stimulus  to  speedy  recovery.  The 
conviction,  however,  proved  to  be  erroneous. 
Many  wounds,  even  after  prompt  and  thorough 
treatment,  and  showing  every  indication  of  rapid 
aseptic  healing,  reached  base  hospitals  a  few 
days  later  in  a,,  deplorable  state  of  rife  sepsis 
which  could  be  explained  only  by  the  prema- 
ture evacuation. 

Wide,    savage    wounds;    unsanitary    and    ex- 
hausting conditions  of  living ;  and  delay  in  treat- 


nient,  all  contributed  generously  to  the  develop- 
ment of  surgical  shock.  Often  the  patient's  con- 
dition was  so  critical  that  surgical  inten'ention  in 
the  wound  had  to  he  postponed,  or  at  least 
limited  to  an  unsatisfactory  minimum,  in  order 
to  snatch  from  impending  death  by  shock  a  man 
who  later  succumbed  because  of  the  delay  to 
gross  infection.    It  was  ever  a  vicious  circle. 

The  soil  of  the  lengthy  battle  front  had  for 
centuries  been  intensively  cultivated  and  gener- 
ously fertilized  until  its  upper  layer  teemed  with 
bacteria,  more  especially  anaerobes.  This  was 
the  soil  that  smirched  the  bodies  and  caked  the 
clothing  of  the  soldiers,  whence  it  was  carried 
into  the  depths  of  wounds  and  lodged  in  bat- 
tered tissue  bereft  of  all  natural  power  to  resist 
invasion.  There  the  micro-organisms  found  ideal 
homes  where  they  flourished  and  multiplied. 

Finally  the  huge  numbers  in  the  contending 
armies,  far  exceeding  all  past  experience,  at 
times  flooded  available  hospitals  and  over- 
whelmed local  facilities.  It  was  often  physically 
impossible,  therefore,  to  give  prompt  and 
thorough  treatment  to  all  cases;  the  greatest 
good  of  the  greatest  number  had  to  be  the  rule. 
A  single  case,  even  if  urgent,  had  to  wait,  if  it 
would  absorb  time  in  which  a  dozen  others, 
equally  urgent  but  requiring  less  time,  could  be 
cared  for.  Time  spent  on  moribund  cases  was 
time  wasted. 

Such  were  the  conditions  that  had  to  be  ac- 
cepted ;  the  problem  of  the  Medical  Corps  was 
to  produce  results  in  spite  of  them.     Infection 


was  the  dominatingc  evil ;  therefore,  the  preven- 
tion of  infection  became  the  crying  need.  Every- 
thing was  subordinated  to  that  one  purpose ;  the 
measure  of  every  procedure,  of  every  invention, 
of  every  act,  was  whether  or  not  it  prevented  in- 
fection. If  it  did  all  good  and  well ;  if  not,  it 
was  ruthlessly  discarded. 

General  measures  that  had  to  do  with  the 
health  and  comfort  of  the  men  were  promptly 
enforced.  Shorter  hours  of  duty  in  the  front 
line  trenches,  still  further  ameliorated  by  fre- 
quent reliefs,  furnished  helpful  periods  of  rest, 
afforded  welcome  opportunities  for  drying  and 
changing  clothing,  and  best  of  all  allowed  more 
regular  distribution  of  warm  food.  There  were 
times  of  course  when  this  happy  routine  was 
rudely  interrupted  by  enemy  activity,  but  for  the 
most  part,  especially  in  the  long  stretches  of  so- 
called  quiet  sectors,  it  was  preserved.  Gradually 
engineers  changed  and  added  to  the  first  hastily 
dug  trenches  until  they  became  more  roomy  and 
livable.  Drainage  measures  were  instituted,  and 
where  the  soil  or  location  was  less  favorable 
pumps  or  other  devices  for  removing  the  excess 
of  water  were  installed.  Delousing  stations  and 
bathing  facilities  were  set  up  far  in  the  rear  at 
so-called  rest  depots  where  regularly  whole  regi- 
ments at  a  time  were  allowed  for  several  days 
absolute  rest  from  duty  and  forced  to  clean  uo. 
First  aid  and  regimental  dressing  stations  were 
pushed  close  to  the  front  line  trenches,  and  field 
and  evacuation  hospitals  were  brought  farther 
forward   for   the   purpose   of    rendering   earlier 


10 

surgical  attention.     The  kind  of   treatment  af- 
forded the  wounded  in  the  earliest  stages  is  re- 
flected in  the  whole  course  of  their  suhsequent 
illness ;  and  no  amount  of  surgical  skill  can  undo 
an  error  previously  committed.     Transportation 
of  the  wounded  was  speeded  up  and  so  well  cor- 
related among  separate  units  that  not  infrequent- 
ly casualties  demanding  urgent  operation  reached 
the  proper  hospital  within  a  few  hours.     Motor 
ambulances  alone  made  this  possible.     In   fact; 
the  motor  ambulance  is  the  very  foundation  on 
which  surgery  at  the   front  is  based.     On  the 
other    hand    premature    evacuation    of    patients 
already    operated    was    retarded.      Unless    the 
wounded  could  be  safely  held  at  the  place  of 
operation  for  a  reasonable  length  of  time,  it  was 
best  to  evacuate  them  unoperated.     The  delay 
occasioned  by  the  postponement  of  definitive  sur- 
gery was  far  less  injurious  than  the  damage  done 
to  a  healing  wound  by  the  exigencies  of  a  trying 
journey.      Every    effort    was    made,    therefore, 
through  early  classification  of  cases  to  make  the 
first  transfer  the  final  one,  or  at  least  to  hold 
operated  cases  at  the  place  of  operation  for  about 
ten  days.     Special  shock  teams  and  rooms  were 
established   at   designated   points   where    special 
treatment  could  be  promptly  and  vigorously  car- 
ried out.     The  urgent  but  time  consuming  cases 
that   had   to  wait   when  the   rush   was  greatest 
came  to  be  better  handled  through  the  creation 
of  observation  wards.    There  doubtful  and  post- 
poned  cases   were   segregated.      If   mixed   with 
other  wounded  men  these  cases  were  liable  to 


11 

be  overlooked.  Each  man  was  tagged  with  the 
name  of  a  surgeon  whose  duty  it  was  to  visit  all 
his  observation  cases  at  stated  intervals  to  the 
end  that  he  not  only  might  not  forget  them,  but 
also  that  he  might  be  regularly  made  cognizant 
of  their  condition.  In  this  manner  cases  were 
often  sandwiched  in  between  operations  and  lives 
saved  that  would  otherwise  have  been  lost.  All 
these  measures  aimed  at  conserving  human 
vitality  and  enhancing,  or  at  least  preserving, 
natural  resistance  against  disease,  to  the  end 
that  the  individual's  own  defenses  against  infec- 
tion should  be  brought  to  the  point  of  maximum 
strength. 

Asepsis  and  Antisepsis. 
With  all  indirect  measures  in  full  swing  there 
remained  to  he  prosecuted  the  direct  attack 
against  infection  of  wounds.  With  asepsis  a 
failure,  surgical  thought  went  back  to  Listerian 
days  and  keen  search  was  instituted  for  anti- 
septics. Every  day  produced  a  new  compound, 
mixture,  or  solution  that  enjoyed  fleeting  fame 
by  its  enthusiastic  sponsor  until  supplanted  by 
to-morrow's.  Their  legion  merely  attested,  not 
their  futility,  but  their  universal  shortcomings. 
Many  of  them  were  of  considerable  value,  and 
some,  like,the  "Bipp"  preparation  of  the  English, 
certainly  at  least  in  the  hands  of  enthusiastic  fol- 
}owers,  gave  happy  results.  But  one  and  all  had 
a  common  failing :  in  spite  of  proved  bacteri- 
cidal power  ultimate  healing  of  wounds  was 
strung    over    a    considerable    period    of    time. 


12 

Gradually,  however,  from  out  the  chaos  there 
arose  accepted  principles  that  grouped  them- 
selves about  one  fundamental  idea,  the  closure 
of  wounds.  So  much  of  asepsis  survives.  The 
axiom  that  a  wound  cjosed  by  suture  or  other 
means  healed  more  promptly  and  with  less  dan- 
ger of  infection  was  not  disputed ;  the  problem 
was  to  close  these  war  wounds  with  impunity. 

Debridement. 

Through  painstaking  bacteriological  and  path- 
ological study  of  wounds  it  was  learned  that  even 
in  the  face  of  the  wretchedly  vile  and  dirty  con- 
ditions under  which  wounds  were  inflicted,  the 
tissues  were  for  the  first  eight  or  ten  hours  not 
infected  but  merely  contaminated.  Bacteria 
were  present  but  had  not  established  a  favorable 
habitat  for  themselves.  If,  therefore,  the  wound 
could  be  treated  within  that  period  and  if  all  the 
contamination  could  be  removed,  the  wound 
could  be  closed  and  aseptic  healing  expected. 
Practice  proved  the  theory  correct.  Casualties 
received  within  the  first  eight  to  ten  hours  had 
their  wounds  completely  excised,  in  one  mass  if 
possible,  under  rigid  aseptic  technique, — the  de- 
bridement of  the  French.  The  excision  had  to 
be  bold,  ruthless,  extensive,  limited  only  by  or- 
gans not  to  be  cut.  Attrition,  cellular  compro- 
mise, and  devitalized  tissue  extend  always  one 
and  often  even  two  centimeters  outside  the  ac- 
tual track  of  the  wound.  Much  has  to  be  sacri- 
ficed ;  large,  but  not  essential  vessels  tied  off ; 
fascia  excised  ;  and  muscles  cut  even  trasversely. 


13 

Ideal  debridement  is  the  removal  of  the  intricate, 
ramifying  walls  of  the  wound  in  one  mass  in 
such  a  manner  that  the  knife  passes  through  only 
sound  and  uncontaminated  tissue.     It  becomes 
imperative,  therefore,  to  recognize  tissue  show- 
ing but  the  slightest  and  earliest  evidence  of  im- 
pending destruction,  a  condition  that  has  been 
aptly  called  local  tissue  stupor.     Such  tissue  is 
damaged,  not  dead  but  prone  to  die,  and  almost 
certain  to  succumb  to  infection.    It  is  character- 
ized by  dryness,  lifelessness,  anemia,  and  in  the 
case  of  muscles  by  insensitiveness  or  sluggish- 
ness of  response  to  stimuli.    All  such  tissue  must 
be  excised.    It  is  far  better  to  cut  away  too  much 
and  be  safe  than  to  preserve  doubtful  tissue  and 
watch  apprehension  turn'  to  certainty  of  infec- 
tion.   Furthermore  no  sinuous  tracks  leading  to 
potential  cavities  can  be  passed  by ;  no  shreds  of 
hanging  tissue  nor  loose  fragments  of  bone  can 
be  left  behind ;  and  no  bits  of  shell  or  clothing 
can  be  overlooked  in  the  depths  of  the  wound. 
Covering  the  entire  interior  of  the  wound  with  a 
solution  of  brilliant  green  which  stains  all  tissues 
a  uniform  shade  makes  a  helpful  guide.     Exci- 
sion completed,  clean  gloves  are  donned  and  a 
new  set  of  instruments  used.     Not  a  small  fac- 
tor determining  success  is  absolute  hemostasis ; 
for  a  small  blood  clot  may  allow  the  propagation 
of  a  few  bacteria  inadvertently  left  behind  that 
fresh    normal    tissue    would    destroy.      At    this 
point  ,the   repair   of    important    structures   that 
have  been  damaged  must  be  accomplished.  Sev- 
ered tendons   should  be  sutured  by  a  nice  ap- 


14 

proximation  of  the  cut  ends.  Divided  nerve 
trunks  are  to  be  carefully  sought  for  and  united. 
Immediate  suture  of  blood  vessels  is  rarely  in- 
dicated because  when  main  trunks  are  injured 
shock  and  hemorrhage  intervene  to  prohibit  any 
such  extended  surgical  procedure.  Even  if 
sutured  the  attempt  is  very  liable  to  be  followed 
by  aneurysm.  As  a  matter  of  fact  large  arteries 
are  rarely  wounded.  They  are,  however,  often 
contused.  When  there  is  considerable  contusion 
or  doubt  as  to  the  p>ermanent  continuity  of  the 
vessel  wall  it  is  best  to  ligate  in  two  places  rather 
than  incur  the  risk  of  subsequent  aneurysm. 
Deep  muscles  are  then  loosely  approximated  with 
as  few  sutures  of  cat-gut  as  possible  and  the 
skin  closed  without  drainage.  Wounds  thus 
treated  within  eight  to  ten  hours  of  infliction  will 
heal  by  first  intention  in  about  90  per  cent,  of 
the  cases  in  soft  parts,  and  in  about  50  per  cent, 
in  compound  fractures. 

The  post-operative  care  is,  however,  of  vital 
importance.  Every  wound  must  be  splinted  and 
so  splinted  as  not  only  to  insure  absolute  rest  to 
the  part  involved,  but  also  to  preserve  immobility 
until  healing  is  obtained.  In  fact  rest  is  so  es- 
sential a  factor  that  early  evacuation  to  the  rear 
or  to  home  hospitals  proved  in  itself  a  potent 
cause  of  failure  to  obtain  first  intention.  It 
therefore  becomes  a  rigid  rule  that  if  the  case 
cannot  be  safely  held,  at  the  place  of  operation 
for  ten  days,  it  is  far  safer  not  to  attempt  im- 
mediate suture  of  the  wound  but  to  be  content 
with  debridement  only. 


15 

Delayed  Suture. 

A  large  percentage  of  the  wounded,  ho\vever, 
could  not  of  necessity  be  treated  within  the 
eight  to  ten-hour  period  essential  for  primary 
suture.  Also,  many  cases  treated  within  that 
period  had  to  be  immediately  evacuated  because 
of  the  exigencies  of  the  military  situation.  Corol- 
laries of  the  eight  to  ten-hour  dictum  are  that 
the  chance  of  rendering  a  wound  aseptic  by  de- 
bridement after  an  interval  of  twenty-four  hours 
is  small;  after  forty-eight  hours,  nil.  Up  to 
twenty-four  hours,  however,  the  chance  is  to  be 
taken  and  is  often  surprisingly  successful.  These 
wounds  are  to  be  treated  by  thorough  debride- 
ment and  absolute  hemostasis.  Sutures  for 
closing  the  wound  are  then  placed  but  not  tied 
and  a  large  aseptic  dressing  applied.  At  the  end 
of  twenty-four  hours  and  again  at  the  end  of 
forty-eight  hours  cultures  of  the  wound  are 
made,  and  if  the  first  shows  no  streptococci  and 
the  second  a  level  or  falling  bacterial  count,  the 
sutures  can  be  safely  tied  with  expected  primary 
healing  in  about  60  per  cent,  of  all  cases.  This  is 
the  so-called  primary  delayed  suture  of  Duval. 
It  is  an  equally  useful  procedure,  in  fact  the  one 
indicated,  in  those  cases  which,  though  otherwise 
favorable  for  primary  suture,  have  to  be  evacu- 
ated prematurely. 

So  well  established  are  the  principles,  so  well 
defined  are  the  indications,  so  precisely  devel- 
oped is  the  technique,  and  so  brilliant  are  the 
results,  that  primary  or  delayed  primary  suture 
of  every  wound  must  be  acknowledged  the  treat- 


16 

ment  par  excellence.  No  other  method  even  ap- 
proaches it  in  rapidity  of  healing,  absence  of 
infection,  and  freedom  from  deformity  or  im- 
paired function.  It  is  a  step  forward  in  aseptic 
technique  unequalled  since  the  birth  of  asepsis. 
To  refuse  it  to  a  patient  in  civil  life  when  under 
unfavorable  war  conditions  it  proved  so  success- 
ful must  now  be  regarded  just  as  surgically 
criminal  as  would  be  the  employment  to-day  of 
the  crude  and  obviously  septic  procedures  of 
our  fore-fathers.  While  it  is  highly  proba])le 
that  the  future  will  bring  forth  a  perhaps  equally 
notable  advance,  it  will  do  so,  not  by  a  miracu- 
lous jump  from  some  rear  position,  but  onl/ 
through  a  cautious  progress  from  this  well  sup- 
ported forward  station. 

Carrel-Dakin  Treatment. 

When  all  is  said  and  done,  however,  it  is  in 
the  violently  infected  wounds  which  for  the  time 
being  seemed  hopeless  that  the  greatest  contribu- 
tion to  surgery  is  found.  Dr.  Carrel  and  Dr. 
Dakin,  after  patient  intensive  study,  developed 
and  perfected  the  technique  that  bears  their  joint 
names.  To  Dakin  belongs  the  credit  of  discover- 
ing the  most  ideal  antiseptic  known :  painless, 
actively  germicidal,  and  harmless  to  normal  tis- 
sue. To  Carrel  goes  the  credit  of  developing  the 
technique  that  allows  the  antiseptic  to  produce 
its  maximum  effect. 

Very  briefly  Dakin's  antiseptic  is  a  solution  of 
sodium  hypochlorite  (NaOCL)  of  a  strength  be- 
tween 0.45  per  cent,  and  0.5  per  cent,  and  faintly 


17 

alkaline  to  alcoholic  phenolphthalcin  but  not  to 
powdered.  Unless  made  to  conform  exactly  to 
these  limitations  it  not  only  loses  its  virtues  but 
becomes  irritating,  even  harmful.  The  solution 
is  very  unstable,  losing  its  strength  rapidly  in 
the  light  and  slowly  even  under  the  best  condi- 
tions in  time.  It  must  therefore  be  freshly  made 
as  needed  and  kept  in  closely  stoppered,  deeply 
colored,  brown  bottles  protected  from  the  light. 
The  early  and  tedious  methods  of  manufacture 
have  been  replaced  by  the  quick  and  efficient 
method  of  passing  chlorine  gas  in  metered  quan- 
tity through  a  measured  solution  of  sodium  car- 
bonate for  a  calculated  length  of  time.  The  nec- 
essary apparatus  has  been  so  perfected  and  sim- 
plified that  the  manufacture  of  perfect  Dakin's 
solution  is  now  within  the  reach  of  alP.  It  is 
absolutely  essential  that  every  liter  made  be  tit- 
rated with  decinormal  sodium  thiosulphate  and 
tested  with  both  powdered  and  alcoholic  phen- 
olphthalcin in  order  to  insure  that  the  solution 
has  the  proper  strength  and  alkalinity.  Both 
tests  must  always  be  made,  for  the  correctness  of 
strength  does  not  at  all  insure  the  correctness  of 
alkalinity.  Also  any  Dakin's  solution  kept  for 
twenty-four  hours  or  longer  must  be  again  tested 
before  using.  Its  instability  is  annoying  and  pre- 
cludes any  short  cut  to  success.  A  variation  of 
even  0.05  per  cent,  in  strength  spells  either  dis- 

^The  apparatus  designed  and  manufactured  by  Wal- 
lace and  Tiernan  Co.,  Inc.,  New  York  City  is  eminently 
satisfactory.  Each  outfit  is  accompanied  by  a  small 
booklet  giving  full  directions  for  setting  up  the  appa- 
ratus, making  Dakin's  solution,  and  testing  the  product. 


18 

aster  or  ineffc'ctiveiiess  according  as  tlie  varia- 
tion is  high  or  low. 

Tlie  action  of  Dakin's  sokition  depends  pri- 
marily on  the  liberation  of  chlorine.  Introduced 
into  the  tissues  this  liberation  is  completed  in 
from  ten  to  fifteen  minutes.  Its  action  would, 
therefore,  be  almost  ineffectually  fleeting  were  it 
not  for  the  redeeming  fact  that  by  the  action  of 
Dakin's  solution  on  tissue  secretions  chloramine 
bodies  are  formed  whose  antiseptic  properties 
are  considerable  and  whose  action  is  prolonged. 
In  addition  to  its  antiseptic  power  Dakin's  so- 
lution possesses  to  a  high  degree  the  ability  to 
dissolve  pus.  slough,  and  necrotic  tissue  in  a 
most  surprising  rapidity  of  manner.  This  in  it- 
self is  a  most  valuable  attribute.  Most  of  the 
ordinary  antiseptics  are  prevented  from  essen- 
tial, intimate  contact  with  bacteria  by  the  pro- 
tective masses  of  blood  and  leucocytes  which  sur- 
round them  and  on  which  most  antiseptics  have 
no  destructive  action.  Dakin's  solution  is  so 
prone  also,  not  to  dissolve  blood  clot,  but  by 
its  solvent  action  on  fibrin  to  dissolve  the  fine 
fibers  that  hold  the  clot  in  place  and  thus  detach 
it  in  mass,  that  this  contingency  must  be  safe- 
guarded by  obtaining  primary  and  complete 
hemostasis  in  all  wounds  to  be  Dakinized.  Last, 
but  not  least,  its  prolonged  action  on  normal  skin 
is  so  irritating  that  the  integument  everywhere 
adjacent  to  the  wound  must  be  vigilantly  pro- 
tected by  some  sort  of  bland  grease. 

Because,  therefore,  of  its  quite  unique  prop- 
erties   Dalcin's   solution   becomes   effective    only 


19 

uhen  used  in  such  manner  as  makes  use  of  those 
properties.  The  technique  evolved  by  Carrel  is 
the  only  technique  that  correctly  utilizes  these 
properties  in  the  way  that  brings  about  the  de- 
sired end,  sterilization  of  the  wound.  Four 
equally  important  and  interdependent  steps  ef- 
fect wound  sterilization.  The  first  may  be 
named  mechanical  cleansing.  This  calls  for  ex- 
pert and  radical  surgery,  good  surgery  in  every 
sense  of  the  word,  and  most  of  all  for  sound 
judgment.  Depending  on  the  lapse  of  time  since 
the  injury  was  inflicted,  wounds  are  found  to 
fall  into  two  main  types :  first  a  phlegmonous 
type  characterized  by  violent  and  unchecked  in- 
fection with  marked  constitutional  symptoms  ; 
and  secondly,  a  frankly  suppurating  type,  the 
sequel  of  the  first,  in  which  infection  has  be- 
come localized  and  general  symptoms  mild  or 
absent.  Between  the  two  lie  borderline  cases 
demanding  great  nicety  of  judgment.  In  the 
phlegmonous  type  too  much  surgery  is  danger- 
ous. All  thought  of  complete  excision  of  the 
wound  must  be  sternly  repressed  in  favor  of 
superficial  cleansing,  removal  of  gross  and  easily 
found  foreign  bodies,  and  multiple  incisions  to 
secure  free  and  ample  drainage  of  every  recess 
of  the  wound,  measures  just  sufficient  to  render 
its  whole  aspect  suitable  for  later  management. 
More  radical  interference  is  certain  to  open  up 
new  channels  for  infection  and  invite  its  spread 
in  spite  of  future  treatment.  In  the  frankly  sup- 
purative type,  however,  bold  surgery  is  far  less 
dangerous,  in   fact,  generally  indicated,  though 


20 

(»ften  best  postponed  until  some  of  the  infection 
:it  least  has  been  conquered.  If  operation  is 
elected,  the  radical  debridement  already  empha- 
sized in  the  primary  suture  of  wounds  is  to  be 
practiced,  but  with  great  discretion.  Nature's 
own  defensive  wall  must  not  be  breeched  but 
jealously  conserved.  Obviously  dead  tissue, 
hanging  shreds,  loose  fragments  of  bone,  all 
bits  of  clothing  and  shell  as  predetermined  by 
X-ray  examination  must  be  removed,  and  in  ad- 
dition pockets,  sinuses,  and  branching  cavities 
must  be  freely  laid  open  even  at  some  risk  of 
extending  infection ;  for  the  success  of  the  next 
step  leans  heavily  on  the  creation  at  this  time 
of  a  wide  open  wound,  of  even  contour,  roughly 
cup  or  saucer  shaped,  with  its  greatest  dimension 
at  its  exit  in  the  skin. 

The  second  step  is  the  chemical  cleansing  of 
the  prepared  wound.  This  is  the  unique  step 
in  the  Carrel-Dakin  technique,  though  by  no 
means  the  most  important.  So  interdependent 
are  the  four  necessary  steps  that  the  second, 
however  nicely,  persistently,  and  devotedly  it 
may  be  pursued,  fails  always  when  its  predeces- 
sor has  been  improperly  executed.  The  agent 
employed  for  chemical  cleansing  is  of  course 
Dakin's  solution.  Other  agents  used  in  exactly 
the  same  way  as  controls  have  universally  failed 
to  sterilize  wounds  with  the  rapidity,  thorough- 
ness, and  positiveness  that  Dakin's  solution  ef- 
fects. Nor  will  Dakin's  solution  applied  to  the 
wound  by  any  method  except  Carrel's  accomplish 
at  all  brilliant  results.    The  antiseptic  must  flood 


21 

the  wound  completely.  Ubiquitous  dispersion  of 
the  agent  is  assured  by  instilling-  it  into  the 
wounds  through  rubber  tubes  left  open  at  the 
ends  or  with  the  ends  closed  and  perforated  at 
the  sides.  So  exact  and  scientific  is  every  point 
in  the  technique  that  the  slightest  deviation  from 
the  blazed  path  invites  failure.  The  calibre  of 
the  tubing;  its  firmness  and  thickness  of  wall; 
the  number  and  size  of  the  lateral  perforations, 
have  all  been  worked  out  according  to  physical 
laws  that  must  be  obeyed^.  Enough  Carrel  tubes 
are  laid  in  the  depths  of  the  wound  and  along 
its  sides  to  insure  the  delivery  of  solution  to 
every  area,  held  in  position  by  lightly  packed 
sterile  gauze,  and  brought  out  of  the  wound  at 
its  highest  anterior  angle.  The  tubes  must  be 
long  enough  to  project  well  beyond  the  bounti- 
ful dressing  of  gauze  that  covers  the  wound  as 
well  as  the  retaining  bandage  or  swathe.  The 
Carrel  tubes  are  then  joined  through  branching 
tubes  of  glass  to  one  large  rubber  tube  with  a 
clamp  that  leads  to  a  dark  brown  glass  reservoir 
suspended  above  the  patient.  The  reservoir 
holds  the  Dakin's  solution,  which  by  releasing 
the  clamp  is  allowed  to  flow  by  gravity  through 
the  tubes  into  the  wound  whence  it  seeps  out 

^Instillation  tubes  are  of  rubber  with  an  inner  diame- 
ter of  4  mm.,  and  a  thickness  of  wall  of  1  mm.  Single 
opening  tubes  are  30  cm.  long,  ends  left  open,  but  a 
small  side  opening  made  near  the  wound  end  to  act  as 
a  safety  valve  in  case  the  end  opening  becomes  plugged. 
Side  perforated  tubes  are  of  four  sizes,  5,  10,  15,  and  20, 
respectively.  The  first  two  are  30  cm|  long,  the  remain- 
ing, 40  cm.  The  ends  are  tied  off  with  linen  thread. 
Beginning  at  the   closed   end  the   sides   are  perforated 


22 

into   the   dressing.      Instead    of    connecting   the 
tubes  to  a  reservoir  each   Carrel  tube  may  be 
left  lying  independently  outside  the  dressing  and 
Dakin's   solution   instilled    separately   into   each 
from  a  glass  syringe.    At  first  the  wounds  were 
subjected  to  continuous  instillation  by  so  loosen- 
ing the  clamp  that  a  definite  amount  of  solution 
was  allowed  to  flow  drop  by  drop  in  a  given 
time.  This  was  found  to  be  exceedingly  difficult 
to  keep  regulated  and  had  the  disfavor  of  keep- 
ing   the    patient    constantly    wet.      Experience 
proved   that   after  an   instillation   of   a   definite 
amount  it  took  at  least  two  hours  for  bacteria 
to  recover  from  the  shock  of  the  antiseptic,  so 
that   continuous    instillation    has   given    way   to 
intermittent,  once  every  two  hours  day  and  night. 
It  might  appear  on  first  thought  that  nocturnal 
instillations  every  two  hours  would  so  seriously 
interrupt   the   patient's    rest   that   their   general 
condition  would  sufifer.     This  is  really  far  from 
being  the  case.    After  the  first  night  or  two  pa- 
tients seldom  are  awakened  by  the  instillations ; 
in  fact  it  is  not  at  all  unusual  for  them  to  doubt 
the  most  conscientious  attendant's  word  that  the 
instillations    were    faithfully    given    while    they 
themselves  slept.    The  amount  to  be  used  at  each 

every  cm.  for  the  number  of  cm.  indicated  by  the  num- 
ber of  the  tube.  The  perforations  are  0.5  mm.  in 
diameter  and  are  made  with  a  special  punch.  Covered 
tubes  are  simply  side  perforated  tubes  covered  with 
Turkish  toweling  which  covers  the  tube  5  cm.  beyond 
the  last  side  opening.  Special  tubes  are  No.  3,  per- 
forated every  half  cm.  for  3  cm.:  loop  tubes,  70  cm, 
long,  perforated  in  the  mid  portion;  and  empyema 
tubes,  50  cm.  long,  perforated  every  cm.  for  10  cm.,  and 
stiflfencd  with  No.  22  gauge  silver  wire. 


23 

instillation  cannot  be  expressed  in  definite  meas- 
ure, for  conditions  vary.  A  larj^e  wound  requires 
more  than  a  small  one ;  the  more  tubes  in  a 
wound  the  more  fluid  is  necessary,  etc.  The 
purpose  is  just  to  fill  the  wound ;  too  much  is 
mere  waste  and  wets  the  patient ;  too  little  leaves 
some  part  of  the  wound  untouched  which  can  be 
easily  recognized  and  corrected  at  subsequent 
dressings. 

Because  of  its  irritating  propensity  to  normal 
skin,  the  integument  everywhere  adjacent  to  the 
wound  which  is  liable  to  be  bathed  by  the  solu- 
tion must  be  protected.  The  best  protection  is 
gauze  impregnated  with  vaseline  mixture^.  Just 
before  the  dressing  is  applied  layers  of  this 
vaseline  gauze  are  laid  on  the  skin  about  the 
wound  and  ironed  out  smoothly.  Occasionally 
this  fails  to  protect  and  a  firmer  substance  must 
be  used  such  as  zinc  oxide  ointment  generously 
smeared  around  the  wound.  Rarely  there  is  en- 
countered in  the  blue-eyed,  freckled  type  of  in- 
dividual a  skin  that  nothing  will  protect  and 
the  only  recourse  is  to  use  Dakin's  on  alternate 
days  or  not  at  all. 

Aside  from  the  regular  day  and  night  instilla- 
tions every  two  hours  these  wounds  need  atten- 
tion only  once  a  day  when  they  should  be  com- 
pletely redressed.     To  insure  rapid  sterilization 

^A  perfectly  tight  tin  box  is  filled  with  pieces  of  gauze 
9  by  17  cm.  The  box  and  its  contents  are  sterilized  by 
steam.  While  still  hot  the  box  and  gauze  are  filled  with 
a  melted  solution:  vaseline  92%,  hard  paraffine  6%, 
resin  2%.  When  cooled  it  is  easy  to  pick  up  as  needed 
single  thicknesses  of  gauze  which  are  found  to  be  thor- 
oughly impregnated  with  the  vaseline  mixture. 


24 

the  dressings  must  be  done  under  rigid  asepsis. 
With  a  little  practice  the  entire  procedure  can 
be  carried  out  easily  with  instrumental  tech- 
nique ;  the  bare  hands  touch  nothing  and  need 
not,  therefore,  be  rendered  surgically  clean.  An 
assistant,  or  even  the  patient  himself,  removes 
the  entire  dressing  tubes  and  all.  It  is  surpris- 
ing to  find  how  painless  are  all  manipulations 
about  Dakinized  wounds.  There  is  no  sticking  of 
gauze  to  be  forcibly  and  painfully  freed  carry- 
ing with  it  strips  of  budding  epithelium  and 
leaving  behind  a  raw,  bleeding,  tender  surface. 
If  the  technique  is  being  properly  carried  out  the 
gauze  slips  away  leaving  bright  pink,  healthy 
granulations  covered  with  viscid,  shiny  fluid, 
colorless,  odorless,  and  at  times  stringy.  Iso- 
lated collections  of  pus  or  areas  of  slough  de- 
note regions  that  Dakin's  solution  failed  to  reach, 
indicating  that  the  positions  of  the  tubes  must 
be  altered  or  more  tubes  inserted  to  correct  the 
defect.  The  wide  open  wound  is  first  irrigated 
thoroughly  but  gently  with  Dakin's  and  the 
excess  allowed  to  run  oft.  The  granu- 
lations and  especially  the  surrounding  skin 
are  gently  scrubbed  with  a  solution  of  neutral 
soap  or  gasoline  until  every  caked  bit  of  blood 
or  flake  of  crusted  serum  is  removed.  It  is  be- 
neath such  detritus  that  bacteria  flourish  and 
prevent  sterilization.  The  wound  is  then  again 
gently  washed  with  Dakin's  solution  and  re- 
dressed exactly  as  at  the  initial  dressing  when 
it  is  ready  for  another  twenty-four  hours.  With  a 
little  experience  and  competent  team-work  these 


25 

dressings  can  be  done  with  great  rapidity  and 
pleasure  to  patient  and  surgeon  alike.     The  ab- 
sence of  pus  and  lack  of  odor  from  these  wounds 
are  as  remarkable  as  the  painlessness  is  surpris- 
ing; and  the  healthy  appearance  of  wounds  and 
patients   is   surpassed   only   by   the    rapidity   of 
heahng.      Hard,   bright    red   granulations    grow 
with  astounding  speed  quickly  filling  the  wound. 
Very  early  the  epithelial  edge  begins  to  prolif- 
erate.    The  thin  blue  line  of  new  cells  widens 
very  slowly  at  first,  but  once  the  wound  is  leveled 
with  granulations  the  rate  of  growth  is  greatly 
accelerated.     This  rate  of  cicatrization  has  been 
closely  studied  under  all  forms  of  treatment  and 
no  other  method  approaches  the  Carrel-Dakin  in 
rapidity.    A  French  physicist  by  means  of  a  most 
ingenious  planimeter  is  able  to  measure  in  square 
centimeters  the  exact  area  of  any  wound  how- 
ever irregular  in  outline.     If  the  daily  diminish- 
ing areas  of  a  healing  wound  be  recorded  on  a 
suitable    chart    a    curve    is    plotted    which    ap- 
proaches   zero.      By   prolonging   this    curve    he 
could    predict    the    day    on    which    cicatrization 
would  be  completed  with  most  uncanny  accuracy. 
Interruption   of   treatment   or   secondary   infec- 
tion, of  course,  disturbs  the  curve  but  curiously, 
if  promptly  corrected,  does  not  afifect  the  predic- 
tion; because   renewed   cicatrization  after   such 
interruption  is  strangely  accelerated. 

The  third  step  is  the  bacterial  count.  As 
soon  as  the  wound  looks  clean  smears  are  made 
daily  with  a  standard  platinum  loop  full  from  the 
least  healthy  appearing  portions  of  the  wound 


26 

and  the  number  of  bacteria  per  field  of  the  mi- 
croscope  carefully    counted.      In    obtaining   the 
smear  blood  must  be  carefully  avoided  for  the 
erythrocytes  rapidly  clump  and  hide  bacteria.  If 
fifty  or  more  bacteria  are  counted  in  the  first  field 
observed   further  examination  is  not  made  and 
the  bacterial  count  is  chartered  as  infinity.     As 
the  count   decreases   at  least   ten   fields,   better 
fifty,   are   counted   and   the   average   computed. 
Almost    without    exception    the    count    rapidly 
diminishes  to  one  or  two  per  field,  and  there- 
after more  slowly.     When  the  count  shows  one 
bacterium  in  five  fields  on  two  successive  days 
the  wound  may  be  safely  regarded  as  surgically 
clean,  except  in  the  case  of  compound  fractures 
where  the  count  of  one  in  five  fields  must  be  ob- 
tained for  five  successive  days.    It  has  been  vigo- 
rously contended,  and  still  is,  that  the  attainment 
of  this  minimum  count  does  not  certify  to  the 
surgical  cleanliness   of   the   wound   unless   it   is 
also  proved  by  cultural   methods  that  none   of 
those  rare  bacteria  are  streptococci.    As  a  matter 
of  fact  it  has  been  so  conclusively  proved  by  cul- 
tural methods  that  wounds  having  only  one  bac- 
terium  in   five  microscopic  fields  never   harbor 
streptococci,    that   the   bacterial   count    alone    is 
sufficient  to  prove  their  absence ;  and  the  court 
of  last  resort,  clinical  experience,  has  ably  dem- 
onstrated that  wounds   deemed   sterile  by  bac- 
terial count  as  often  prove  to  be  so  as  those  so 
determined  by  cultural  methods.     Morever,  cul- 
tural methods  contain  a  deceptive  source  of  un- 
avoidable error.     The  bacteria  held  in  the  loop 


27 

for  culture  may  be  either  accidental  and  transi- 
tory contaminators,  or  may  be  permanent  inhabi- 
tants unacclimated  and  unable  to  grow  in  the 
presence  of  the  defensive  juices  of  the  wound, 
but  when  transfered  to  the  more  suitable  envi- 
ronment of  artificial  culture  media  regain  their 
vitality.  In  either  event  the  conclusions  to  be 
drawn  from  a  positive  culture  are  erroneous  as 
regards  the  real  condition  of  the  wound.  For 
all  practical  purposes,  therefore,  the  much  more 
simple  and  rapid  determination  of  wound  steril- 
ity by  bacterial  count  alone  is  a  perfectly  safe 
criterion.  If  the  bacterial  count  be  regularly 
recorded  on  a  suitable  chart  a  curve  is  drawn 
which  ever  approaches  zero.  The  first  count  is 
invariably  infinity;  but  after  an  initial  rise  about 
the  second  or  third  day  the  count  steadily  de- 
clines with  such  rapidity  that  ordinary  wounds 
of  soft  parts  are  surgically  sterile  in  from  five 
to  eight  days.  More  extensive  wounds  require 
a  longer  time ;  severely  traumatized  wounds, 
two  weeks ;  and  compound  fractures  freed  from 
sequestra  about  four  weeks.  Let  the  treatment 
be  interrupted  and  the  count  instantly  rises.  A 
soldier  patient,  a  mathematician,  while  undergo- 
ing Carrel-Dakin  treatment  ingeniously  worked 
out  a  formula  by  which  from  the  chart  he  could 
calculate  the  day  on  which  the  wound  would  be 
isterile.  While  perhaps  this  formula  may  be  of 
only  academic  interest,  like  the  planimeter  meas- 
ure of  cicatrization,  the  fact  remains  that  in 
many  instances  the  calculated  date  of  sterility 
exactly    coincided    with    the    actual    date,    and 


28 

thereby,  like  the  planimeter,  gave  proof  of  the 
scientific  precision  of  the  Carrel-Dakin  tech- 
nique. 

The  fourth  and  last  step  is  the  closure  of  the 
sterilized  wound, 'the  final  goal,  the  consumma- 
tion of  the  technique,  and  the  measure  of  it;? 
worth.  Because  of  the  delay  involved  this  late 
closure  is  designated  secondary  suture.  The 
time  when  closure  may  be  safely  attempted  is 
when  the  wound  is  pronounced  surgically  clean. 
Earlier  attempt  spells  disaster,  further  delay 
merely  postpones  ultimate  healing.  Generally 
speaking  the  wound  is  healed  eight  days  after 
secondary  suture.  In  all  small  wounds,  and  in 
certain  moderately  large  ones  to  be  determined 
only  by  experience,  it  is  obviously  debatable 
whether  time  will  be  saved  by  secondary  suture. 
These  wounds  are  likely  to  heal  by  themselves 
in  the  eight  days  required  for  closure  by  suture. 
Whenever,  therefore,  the  time  necessary  for 
spontaneous  healing  and  for  healing  by  second- 
ary suture  nearly  coincide,  it  is  wise  not  to  sub- 
ject the  patient  to  the  risk  of  further  operative 
measures,  but  to  allow  the  wound  to  heal  na- 
turally. The  technique  of  secondary  suture  is 
very  simple.  Under  general  anaesthesia  and 
strict  asepsis  the  new  epithelial  margin  of  skin 
and  the  adjacent  granulations  are  excised  as  a 
long  strip  and  the  fresh  wound  edges  brought 
together  with  interrupted  sutures.  Undue  ten- 
sion on  the  stitches  must  be  avoided.  If  the 
wound  fail.s  to  coapt  easily,  undermining  or  other 
plastic  procedure  must  be  invoked.  A  large  asep- 


29 

tic  covering  and  a  comfortable  splint  complete 
the  dressing  which  need  not  be  disturbed  for  a 
week.  There  will  then  be  found  just  the  fine 
linear  scar  that  invariably  follows  suture  of  an 
incised  wound.  It  is,  for  that  matter,  a  happy 
sequela  of  all  Dakinized  wounds  that,  however 
healed,  the  resultant  scar,  irrespective  of  the  size 
of  the  original  wound,  is  never  dense  and  thick 
but  always  thin  and  pliable.  And  in  whatever 
manner  ultimate  healing  is  obtained,  whether  by 
primary  suture,  delayed  primary,  or  secondary 
closure,  the  resultant  scar  must  be  treated  with 
the  greatest  respect.  Dire  experience  has  taught 
that  deeply  imbedded  in  the  scar  isolated  bac- 
teria survive  latently  for  weeks  and  months, 
harmless  if  left  alone.  But  let  the  cicatrix  be 
subjected  to  undue  manipulation  or  insulted  by 
premature  operation  the  sleeping  germs  awaken 
into  violent  activity  that  not  only  undoes  much 
of  the  local  repair  but  even  theatens  life  itself. 
There  can  be  no  question  about  the  matter: 
to  Carrel  and  Dakin  belong  the  credit  for  the 
greatest  surgical  discovery  the  war  has  pro- 
duced. The  idea,  the  possibility  of  sterilizing 
infected  wounds  by  chemical  means,  is  of  course 
the  original  Listerian  one  and  cannot,  therefore, 
be  truthfully  called  new,  but  the  idea  had  been 
practically  abandoned  for  years  in  favor  of 
asepsis,  so  that  Carrel  and  Dakin  must  be  credit- 
ed with  at  least  resurrecting  the  principle  and  re- 
applying it.  In  so  far  as  the  means,  and  espe- 
cially the  agent,  employed  are  concerned  their 
■work  is  indisputably  new,  and  whatever  changes 


30 

may  be  made  in  the  technique  throiig^h  future 
experience,  to  them  will  the  world  be  forever 
indebted  for  their  conquest  of  infection.  That 
the  Carrel-Dakin  technique  actually  accomplishes 
wound  sterilization  has  been  conclusively  proved 
over  and  over  again  until  it  has  earned  its  place 
in  surgery  for  all  time. 

Because  of  such  inherent  disadvantages  of 
Dakin's  solution  as  instability,  arduousness  of 
manufacture,  and  difficulty  of  use,  Dakin  was 
spurred  to  further  effort  and  later  brought  out 
two  more  antiseptics  which  he  named  chloramin 
T  and  dichloramin  T.  While  more  stable  than 
sodium  hypochlorite  they  are  nevertheless  de- 
composed by  light  and  time  and  have  therefore 
to  be  protected.  Like  the  original  Dakin's  solu- 
tion these  are  both  chlorine  compounds  which 
accomplish  maximum  destruction  of  bacteria 
with  minimum  detriment  to  tissue ;  unlike  the 
original  their  application  is  simple,  does  not  de- 
mand special  apparatus,  and  their  manufacture 
is  easy.  While  both  can  be  used  without  irri- 
tation in  much  greater  strength  and  perhaps, 
therefore,  possess  greater  antiseptic  power, 
neither  possesses  the  inestimable  property  of 
dissolving  pus,  blood,  and  necrotic  tissue. 
Chloramin  T  is  soluble  in  water,  more  stable 
and  prolonged  in  action  than  Dakin's  solution, 
and  can  be  used  in  strengths  up  to  2%.  Non- 
toxic and  non-irritating  it  may  be  applied  in 
solution  or  as  impregnated  gauze,  and  is  well 
suited  for  use  in  wounds  already  cleaned  with 
Dakin's   and    free    from    slough.      Mechanically 


31 


combined  with  sodium  stearate  it  forms  a 
whipped  cream  Hke  substance  or  paste,  Dau- 
fresne's  paste,  which  can  be  freely  spread  over 
wounds.  In  this  form  its  action  is  said  to  be 
prolong-ed,  but  its  worth  is  not  yet  satisfactorily 
proven. 

Dichloramin  T  is  completely  soluble  only  in 
oily  media,  best  in  the  specially  prepared  sol- 
vent, chlorcosane.  It  contains  twice  as  much 
chlorine  as  chloramin  T  and  has  a  much 
stronger  germicidal  action.  It  can  be  safely 
used  up  to  a  strength  of  20%,  but  for  general 
surgical  work  a  5%  or  8%  solution  is  sufficient. 
As  a  rule  oily  solutions  are  hindered  by  the  oil 
from  obtaining  intimate  contact  with  infected 
matter  and  hence  possess  little  antiseptic  power. 
Dichloramin  T,  however,  yields  moderate 
amounts  of  antiseptic  to  w^atery  media  such  as 
wound  secretions  and  so  exerts  efficient  germi- 
cidal action.  The  oil  acts  so  to  speak  as  a  reser- 
voir of  available  antiseptic  which  can  be  con- 
stantly drawn  upon  by  the  wound  secretions. 
As  the  store  is  not  exhausted  for  from  eighteen 
to  twenty-four  hours  the  wounds  need  to  be 
dressed  but  once  a  day.  It  is  especially  in- 
dicated in  wounds  that  do  not  require  irrigation 
or  that  have  been  freed  of  all  necrotic  material 
by  Dakin's  solution.  The  oil  nrny  be  sprayed 
from  an  atomizer  or  be  injected  from  a  glass 
syringe.  Contaminated  wounds  have  been 
treated  from  the  start  wath  dichloramin  T  with 
most  gratifying  success.  After  careful  de- 
bridement   and    absolute    hemostasis    the    fresh 


32 

surface  is  well  covered  with  the  oil  and  the 
wound  immediately  sutured  without  drainage. 
Older  infected  wounds,  prepared  as  for  Dakin's 
solution,  have  also  been  perfectly  sterilized  by 
means  of  dichloramin  T.  The  wound  surfaces 
are  first  covered  with  coarse  mesh  gauze  which 
has  been  thoroughly  impregnated  with  parafifine. 
Then  a  generous  amount  of  oil  is  poured  into 
the  wound  which  is  kept  open  by  a  light  pack- 
ing of  gauze.  Since  there  is  no  excess  solution 
used  and  no  regular  addition  of  fresh  solution 
is  instilled  as  has  to  be  the  case  in  the  Carrel- 
Dakin  technique,  the  amount  of  dressing  ma- 
terial may  be  greatly  diminished,  a  by  no  means 
negligible  economy.  No  further  attention  is 
necessary  or  indicated  for  twenty-four  hours 
when  under  rigid,  aseptic,  instrumental  tech- 
nique all  gauze  is  removed,  the  skin  around  the 
wound  cleaned  with  soap  and  water  followed 
by  benzene,  and  a  new  dressing  applied.  There 
is  no  grievous  sticking  of  gauze  which  slips 
away  painlessl}''  without  leaving  a  raw  bleeding 
surface.  Because  of  its  ease  of  manufacture 
and  application  dichloramin  T  is  an  especially 
appealing  antiseptic ;  but  while  its  germicidal 
power  and  general  efificacy  are  great  it  is  not 
in  the  long  run  as  rapid  in  action  or  as  effective 
as  the  original  sodium  hypochlorite  which  with 
its  additional  unique  solvent  action  on  pus  and 
necrotic  tissue  still  retains  its  place  as  the  most 
perfect  anti.septic  yet   known. 

Tetanus. 
While     the     almost     universal     infection     of 


33 

wounds  with  ordinary  pyogenic  organisms 
caused  anxiety  enough,  two  specific  infections 
came  to  be  regarded  with  special  dread,  tetanus 
and  gas  gangrene.  These  virulent  anaerobic 
bacteria  grew  luxuriantly  in  the  highly  fertilized 
soil  of  France  whence  they  obtained  ready  ac- 
cess to  wounds.  Prewar  knowledge  of  tetanus 
was  already  considerable  and  experience  gained 
in  the  war  did  little  to  shake  that  knowledge  or 
add  to  it.  The  tried  and  proven  prophylactic 
serum  fully  equalled  expectations  in  as  much 
as  its  compulsory  injection  into  every  wounded 
man  almost  completely  stamped  out  the  dis- 
ease ;  but  incidentally  something  new  was 
learned  regarding  its  nature,  action,  and  dosage. 
That  the  severity  of  tetanic  infection  was,  as 
heretofore  believed^  proportionate  to  shortness 
of  the  incubation  period  did  not  always  hold 
true;  in  fact  was  not  infrequently  to  the  con- 
trary. Some  of  the  worst  cases  encountered 
developed  only  after  a  lapse  of  many  days.  A 
first  prophylactic  dose  of  500  units  proved  suf- 
ficient for  ordinary  wounds ;  large  or  very 
dirty  wounds  require  from  1000  to  1500  units. 
A  primary  dose  of  500  units  was  so  rarely  fol- 
lowed by  anaphylactic  shock  incident  to  subse- 
quent injections  that  all  danger  on  that  score 
was  eliminated.  Traces  of  the  first  prophy- 
lactic dose  are  retained  in  the  body  for  twenty- 
one  days  at  the  most  but  in  quantity  to  insure 
immunity  for  only  about  ten  days;  a  second 
dose  is  retained  only  seven  or  eight  days;  and 
a  third  even  less  with  a  proportionately  shorter 


34 

duration  of  immunity.  In  other  words  repeated 
doses  reduce  the  patient's  abiHty  to  hold  anti- 
toxin. While  it  was  found  that  tetanic  patients 
have  in  their  blood  positive  amounts  of  natural 
antitoxin,  the  amount  is  too  small  to  render  last- 
ing immunity.  Postponed  surgery  on  tetanus 
wounds  that  have  been  healed  for  many  months 
is,  therefore,  by  no  means  devoid  of  danger ; 
for  not  only  does  the  bacillus  of  tetanus  linger 
latent  in  the  scar  for  long  periods  ready  to  acti- 
vate when  disturbed,  but  whatever  natural  im- 
munity has  been  acquired  is  impotent,  and  a 
prophylactic  dose  given  just  previous  to  opera- 
tion is  of  fleeting  efficacy.  Of  all  the  possible 
routes  for  the  injection  of  antitetanic  serum  the 
intrathecal  is  the  most  effective  and  most 
rapidly  saturates  the  body,  but  the  subcutane- 
ous or  intramuscular  route  is  preferable  for 
prophylaxis  because  being  more  slowly  ab- 
sorbed its  action  is  more  prolonged. 

From  the  fore-going  facts  a  prescribed 
prophylactic  course  of  treatment  was  instituted 
that  proved  so  effective  that  it  can  be  positively 
reHed  on  to  prevent  tetanus.  Expect  tetanus  in 
all  wounds  was  the  premise.  At  the  earliest 
possible  moment  every  wounded  man  received 
500  units  subcutaneously  or  intramuscularly, 
and  every  seven  days  thereafter  a  similar  dose 
until  four  had  been  given.  If  at  a  later  period 
an  operation  became  imperative  another  dose 
of  500  units  was  administered  forty-eight  hours 
before  operation. 

As  it  is  impossible  to  tell  from  inspection  of 


35 

the  wound  whether  tetanic  infection  is  present 
or  not,  early  signs  and  symptoms  of  the  disease 
must  be  promptly  recognized.  The  classic  sig^s 
of  tetanus  refer  to  a  phase  of  the  disease  in 
which  treatment  has  lost  much  of  its  power  and 
value.  Local  rigidity,  spasticity,  or  jerking  of 
muscles  adjacent  to  the  wound,  especially  at 
night,  are  premonitory  signs  that  precede  the 
classic  symptoms  by  hours,  days,  and  oc- 
casionally even  weeks.  As  the  toxin  of  tetanus 
may  become  generally  distributed  by  the  blood 
stream  as  well  as  by  continuity  of  nerve  tissue, 
similar  local  manifestations  may  appear  at  any 
time  in  muscles  far  distant  from  the  wound. 
All  evidence  of  the  disease  may  be  entirely  con- 
fined to  just  such  localized  manifestations  which 
after  persisting  for  months  gradually  disap- 
pear; but  only  too  often  the  local  signs  are  fol- 
lowed after  varying  intervals  by  all  the  dis- 
tressing evidences  of  generalized  tetanus.  In 
the  light  of  present  knowledge,  therefore,  there 
is  no  excuse  in  the  presence  of  such  local  signs 
for  delaying  either  the  diagnosis  of  tetanus  or 
the  prompt  institution  of  vigorous  treatment. 
Time  is  the  most  effective  factor  in  success.  In 
the  way  of  treatment  the  wound  of  course 
should  be  laid  wide  open.  Carrel-Dakin  treat- 
ment probably  offers  the  best  method  of  local 
attack,  but  the  value  of  any  local  measure  is 
slight.  As  a  matter  of  fact  the  war  has  done 
little  except  to  emphasize  the  futility  of  all  non- 
specific  remedies   and   the   necessity  of   speedy 


36 

massive  doses  of  the  specific  antitoxin  repeated 
without  stint  as  long  as  symptoms  persist. 

Gas  Gangrene. 
In  respect  to  the  other  specific  infection,  gas 
gangrene,  the  story  is  profoundly  different. 
Not  only  was  prewar  knowledge  of  the  disease 
comparatively  meager,  but  its  incidence  and 
morbidity  were  woefully  unsuspected.  Its 
prompt  appearance  on  the  battle  fields  of 
France,  however,  stimulated  investigations  that 
even  if  they  have  not  beyond  dispute  produced 
a  specific  prophylactic  and  curative  agent,  have 
added  greatly  to  knowledge  of  the  disease  and 
given  promise  of  the  early  discovery  of  a  potent 
remedy.  In  the  process  not  a  few  preconceived 
notions  have  been  refuted.  The  cause  of  the 
disease,  for  example,  has  been  found  to  be  due 
not  solely  to  the  bacillus  Welchii,  but  to  a 
variety  of  other  anaerobic,  gas  producing  or- 
ganisms ;  bacillus  sporogenes,  vibrion  septique, 
bacillus  edematiens,  and  less  frequently  bacillus 
histolyticus  and  bacillus  Hibler.  Rarely  from 
one  wound  were  pure  cultures  of  any  one  or- 
ganism obtained ;  very  often  two  or  more  types 
were  found  living  symbiotically  with  aerobes 
which  augmented  their  effect.  The  bacillus 
Welchii  was,  however,  isolated  from  about  75% 
of  all  cases.  The  bacillus  sporogenes  alone  is 
non-toxic  but  shows  a  determined  tendency  to 
grow  symbiotically  with  any  of  the  others 
whose  activity  it  then  enhances.  The  causative 
agent  necessarily  enters  the  wound  as  spores 
which  mature  only  under  anaerobic  conditions. 


37 

It  was  not  at  all  surprising:,  therefore,  to  find 
that  about  70%  of  all  wounds  were  contami- 
nated with  anaerobic  bacteria  which,  however, 
because  of  unsuitable  environment  were  far 
less  often  able  to  infect.  Fresh,  normal  blood 
contains  sufficient  oxygen  to  inhibit  the  growth 
of  these  anaerobes.  Therefore  tourniquets, 
exsanguinated  tissue,  devitalized  and  necrotic 
structures  are  all  so  conducive  to  anaerobic 
growth  that  they  must  be  avoided  or  removed. 
Muscle  tissue  proves  to  be  absolutely  essential 
for  the  production  of  gas  infection;  for  no 
wound  without  muscle  involvement  was  ever  so 
infected.  Once  firmly  implanted  the  bacteria 
grow  with  tremendous  rapidity  and  manufac- 
ture an  exotoxin  that  has  two  special  predilec- 
tions: one  for  muscle  structure  which  it  rapidly 
destroys  with  the  production  of  an  equally 
poisonous  tissue  toxin;  and  the  other  for  blood 
which  it  as  rapidly  hemolyzes.  This  bacterial 
toxin  has  been  isolated  and  from  it  has  been 
made  in  a  manner  similar  to  the  manufacture 
of  diphtheria  antitoxin  a  specific  serum  for 
which  great  hopes  are  entertained.  The  pro- 
duction of  gas  is  rapid  and  voluminous.  It  has 
been  conclusively  proved,  however,  that  the  gas 
itself  is  not  toxic  but  that  by  its  pressure  it  acts 
in  a  very  destructive  mechanical  fashion.  An 
invariable  accompaniment  of  gas  infection  is  the 
more  or  less  rapid  development  of  varying  de- 
grees of  acidosis. 

Pathologically    the    process    extends    rapidly 
along  muscle  bundles  always   in  a  longitudinal 


38 

direction  except  occasionally  when  it  invades 
the  muscle  coat  of  arteries  when  it  may  follow 
the  transverse  course  of  the  vessel  across  the 
muscle.  For  that  reason  it  not  infrequently 
happens  that  only  one  muscle  of  a  group  or 
even  occasionally  but  part  of  one  muscle  is  in- 
volved. The  rapid  production  of  gas  exerts  a 
pressure  that  first  effectually  strangulates 
muscle  bundles  and  deprives  them  of  blood 
oxygen  and  then  later  bursts  the  enclosing  sar- 
colemma  allowing  herniae  of  muscle  fibers. 
The  gas  detected  in  the  subcutaneous  tissue  is 
not  formed  there  but  has  escaped  from  rup- 
tured muscles.  Strangulated  tissue  rapidly  be- 
comes gangrenous.  The  whole  process  extends 
with  the  most  startling  haste.  Gas  has  been 
detected  in  a  wound  within  the  first  five  hours, 
followed  by  complete  gangrene  of  the  limb  and 
death  of  the  patient  within  fifteen  hours. 

It  is  quite  common  to  find  the  disease  divided 
clinically  into  different  types.  One  frequently 
used  classification  is  gas  infection  or  gas  cel- 
lulitis,— a  local  somewhat  benign  manifesta- 
tion,— and  gas  gangrene  which  embraces  the 
severe,  explosive,  fatal  types  with  marked  con- 
stiutional  symptoms.  Attempted  classifica- 
tions on  an  etiological  basis  are  especially  to  be 
condemned,  not  only  because  the  infection  is  in- 
variably mixed,  but  also  because  in  the  present 
state  of  knowledge  the  part  played  by  each  kind 
of  organism  is  not  by  any  means  certain.  In 
this  respect,  however,  it  is  recognized  that  the 
bacillus     cdematiens,     when     once     firmly     im- 


39 

planted,  rapidly  kills  off  other  varieties  and  be- 
comes the  dominating  organism.  Such  cases 
are  as  a  rule  quickly  fatal.  Another  and  finer 
classification  subdivides  into  malignant  gaseous 
edema,  classic  gaseous  gangrene,  toxic  gaseous 
gangrene,  and  mixed.  All  such  attempts  at 
nomenclature  are  not  only  hair  splitting  and 
confusing,  but  unnecessarily  futile.  It  is  per- 
fectly obvious  that  these  are  not  different  types 
of  the  disease  but  merely  different  stages  in  its 
development  to  be  recognized  as  such.  There 
are  mild,  severe,  and  perhaps  even  abortive 
cases  just  as  there  are  of  other  diseases,  de« 
pending  on  such  many  and  complex  factors  as 
the  virulence  of  infection,  natural  resistance  of 
the  patient,  promptness  and  efficacy  of  treat- 
ment, etc.  This  conception  of  the  disease  is  all 
the  more  to  be  accepted  because  of  the  per- 
fectly obvious  and  natural  division  of  the 
process  into  four  distinct  stages  defined  and 
limited  by  bacteriological  and  pathological  find- 
ings. These  stages  may  follow  each  other  with 
startling  haste  at  irregular  intervals,  or  slowly 
and  orderly  without  in  the  least  altering  the 
fundamental  conception.  The  first  is  named  the 
dormant  stage.  The  wound  is  contaminated 
with  the  organism  which  has,  however,  not 
gained  a  sufficient  foot-hold  to  produce  in  the 
wound  the  classical  diagnostic  appearance. 
Nevertheless,  this  is  the  period  in  which  it  is 
imperative  to  make  a  diagnosis;  for  when  the 
old  classical  signs  appear  infection  is  so  rife 
and  so  firmly  seated  that  effective  treatment  is 


40 

difficult.  On  close  observation  it  will  be  noted 
that  the  tissues  in  the  dormant  stage  have  a 
pale,  dried-out  appearance  and  are  unusually 
insensitive  and  bloodless.  The  muscles  have  a 
dull,  brick  red  color,  do  not  twitch  when 
pinched,  do  not  bleed  on  section,  on  percussion 
yield  a  faint  tympanitic  note,  and  lack  normal 
striations.  The  last  named  sign  comes  close  to 
being  diagnostic,  for  muscle,  gangrenous  from 
any  other  cause,  fails  to  show  loss  of  striation. 
X  ray  of  suspicious  muscle  is  also  character- 
istic and  is  seen  in  no  other  process.  The  plates 
show  irregular  light  zones  around  muscle 
bundles,  changing  as  the  infection  progresses  to 
light  spots  growing  ever  larger. 

The  second  stage,  gaseous  distention,  may  ap- 
pear within  a  very  few  hours  or  develop  more 
slowly.  It  is  characterized  by  the  old  classic 
signs :  hard  edema,  bronzed  skin,  sharply  de- 
marked  swelling,  brownish  serous  discharge,  an 
odor  of  putrefaction,  slight  often  imperceptible 
emphysema,  and  such  constitutional  symptoms 
as  dyspnoea,  subnormal  temperature,  pallor, 
and  rapid  pulse.  It  represents  strangulation  of 
tissue,  pressure  from  gas  formation,  and  begin- 
ning gangrene.  Accompanying  the  local  mani- 
festations is  a  rapid  hemolysis  that  may  go  as 
low  even  as  a  million  and  a  half  reds.  The  hard 
edema  and  bronzing  of  the  skin  are  undoubt- 
edly the  result  of  this  marked  hemolysis. 

The  third  stage  is  the  explosive.  There  is 
rapid  ,  progression  of  the  local  destructive 
process    plus    overwhelming    invasion    of    dead 


41 

muscle  with  the  causative  organism.  This  in- 
vasion is  accelerated  by  the  gas  itself.  Myriads 
of  bacteria  adhere  to  the  minute  bubbles  which 
are  forced  by  pressure  along  the  intermuscular 
septa.  Muscle  bundles  rupture  in  quick  succes- 
sion filling  the  wound  secretion  with  fine  bub- 
bles and  distending  the  subcutaneous  tissue 
until  it  crepitates  like  lung  structure.  In  and 
about  the  wound  occurs  a  gelatinous  infiltra- 
tion— edema  plus  hemolysis.  This  gelatinous 
infiltration  forms  readily  between  muscle  layers 
and  spaces  where  its  excellent  anaerobic  posi- 
tion makes  it  an  admirable  culture  media. 
Blebs  filled  with  a  thin  most  offensive  fluid 
burst  forth  in  profusion  on  the  bronzed,  shiny, 
distended  skin.  The  stinking  odor  of  gangrene 
is  everywhere  apparent.  Signs  of  systemic  in- 
volvement make  their  appearance  as  a  begin- 
ning acidosis. 

The  fourth  and  last  stage  is  that  of  systemic 
toxaemia.  It  follows  its  immediate  predecessor 
with  scarcely  a  pause  and  is  itself  of  fleeting 
duration.  To  the  above  sufficiently  distressing 
picture  is  added  delerium  alternating  with  pro- 
found stupor,  rapidly  failing  pulse,  low  blood 
pressure,  high  fever,  dyspnoea,  and  all  the  signs 
of  an  impending  fatal  termination.  The  cause 
of  death  is  not  a  blood  invasion  by  the  micro- 
organisms, not  an  acidosis  which  is  secondary, 
but  a  profound  intoxication  with  definite  and 
very  potent  poisons,  the  exotoxins  from  the  in- 
fecting organisms  and  the  tissue  toxins  from 
the  action  of  the  bacteria  on  muscle  fibers. 


42 

Treatment  to  be  effective  must  be  promptly 
instituted  in  the  dormant  phase.  The  shocking 
mortahty  obtained  early  in  the  war  can  be  laid 
solely  and  surely  to  the  inability  to  make  an 
early  diagnosis.  Cases  reaching  the  fourth 
stage  are  moribund ;  the  third  stage,  almost 
hopeless ;  the  second,  exceedingly  critical ;  the 
first,  hopeful.  Occasionally  because  of  high 
virulence  of  the  infecting  organism,  lowered  re- 
sistance, and  other  equally  deleterious  factors, 
early  diagnosis  and  efficient  treatment  are  un- 
availing and  the  patient  dies.  Not  only  must 
treatment  be  prompt,  it  must  be  energetic. 
Conservative  surgery  has  no  place  in  this  class 
of  infection.  Under  general  anesthesia  the 
wound  must  be  widely  opened  up,  all  contused 
tissue  removed,  and  especially  every  last  bit  of 
muscle  that  fails  to  twitch  or  bleed  when  cut 
must  be  ruthlessly  excised.  To  be  able  to  de- 
tect minute  hemorrhage  from  muscle,  tour- 
niquets during  operation  are  absolutely  pro- 
hibited. In  dealing  with  muscles  it  must  be 
constantly  borne  in  mind  that  the  infection  ex- 
tends longitudinally  and  therefore  every  bundle 
that  shows  the  slightest  evidence  of  involvement 
must  be  courageously  followed  a  little  beyond 
the  gross  limit  of  disease.  Needless  to  say 
every  vestige  of  foreign  material  as  denoted  by 
X-ray  must  be  removed.  The  same  is  true  re- 
garding hematomata.  Clotted  blood  is  an  ideal 
culture  media.  Lay  open  by  longitudinal  in- 
cisions all  suspicious  muscular  and  vascular 
sheaths   for  the  purpose  of   exposing  all  areas 


43 

of  gelatinous  infiltration.  Last  but  not  least 
split  skin  and  aponeuroses  with  parallel  longi- 
tudinal incisions.  Avoid  all  transverse  incisions 
because  of  their  interference  with  the  circula- 
tion of  distal  parts.  After  complete  hemostasis 
has  been  obtained  the  institution  of  Carrel- 
Dakin  treatment  affords  the  best  means  of  ar- 
resting and  overcoming  the  infection.  Ampu- 
tation is  the  measure  of  last  resort.  It  should 
never  be  done  in  the  dormant  stage  until  ef- 
ficient Carrel-Dakin  treatment  proves  unavail- 
ing which  is  not  often  the  case.  Patients  seen 
for  the  first  time  in  the  second  and  third  stages 
very  often  demand  immediate  amputation  in 
order  to  save  life.  It  is  not  by  any  means  al- 
ways necessary  to  amputate  high  well  above  all 
possible  limits  of  infection ;  at  a  point  just  above 
the  area  of  skin  discoloration  has  proved  amply 
sufficient.  All  amputations  should  be  done  after 
the  guillotine  method,  augmented  by  lateral  in- 
cisions through  skin,  subcutaneous  tissue,  and 
fascia,  extending  well  up  the  limb,  followed  by 
Carrel-Dakin  treatment. 

Sodium  bicarbonate  should  be  given  early  in 
large  doses  and  continued  for  many  days  in 
order  to  ward  off  or  mitigate  inevitable  acidosis. 
Antitoxin  can  be  tried  at  any  time.  In  the  criti- 
cal toxaemic  cases  it  is  always  indicated  in  the 
hope  that  it  will  bring  about  sufficient  improve- 
ment to  justify  a  quick  amputation.  The  anti- 
toxin must  be  composed  of  anti-Welchii,  anti- 
edematiens,  and  anti-vibrion  septique ;  one  alone 
is  not  effective.     Each  must  be  prepared  and 


44 

kept  separately,   but  can  be  mixed  just   before 
using. 

Compound  Fractures. 
A  larj;^e  percentage  of  the  battle  wounds  in- 
volved bones.  Compound  fractures,  therefore, 
were  extremely  common.  Not  only  did  these 
lesions  share  the  subsequent  infection  that  com- 
plicated wounds  of  soft  parts,  but  they  also,  be- 
cause they  offered  the  maximum  possibilities, 
succumbed  more  easily  and  clung  more 
tenaciously  to  infection.  Once  the  problem  of 
the  management  of  compound  fractures  was  re- 
duced to  terms  of  prevention  of  infection  and 
vigorous  antiseptic  treatment  great  advances 
were  made.  All  the  heterogeneous  varieties  of 
splints  for  every  conceivable  fracture  were 
scrapped  in  favor  of  a  few  simple  efficient  ones 
that  were  standardized.*  Splints  that  depended 
for  their  immobilization  on  circular  bandages 
that  possibly,  and  often  did,  constrict  circula- 
tion were  discarded  and  preference  was  given 
to  those  that  maintained  equally  good  im- 
mobility through  the  principle  of  extension. 
The  compulsory  immediate  use  of  the  Thomas 
splint  alone  greatly  reduced  the  mortality  from 
compound  fractures,  lessened  the  ravages  of  in- 
fection, and  preserved  countless  limbs  that 
would  otherwise  have  been  sacrificed  by  im- 
perative  amputation.      No   small   factor   in   the 

■•Standardized  splints.  Wire  gauze  6x36  inches,  Jones 
forearm  "cock-up,"  Thomas  traction  arm,  Jones  hu- 
merus traction,  Jones  rectangular  foot,  Cabot  posterior 
wire,  Thomas  traction  leg,  long  Liston,  Bradford  frame, 
Balkan  frame. 


45 

success  claimed  for  the  Thomas  spHnt,  however, 
was  the  strict  observance  of  the  dictum  that  the 
original  splint  remain  undisturbed  irrespective 
of  frequent  transfers  of  the  patient,  until  union 
was  firm.  The  application  of  the  principles  of 
wound  closure  and  sterilization  so  further  im- 
proved the  results  that  Depage  was  able  to  show 
ward  after  ward  filled  with  cases  of  compound 
fracture  without  a  drop  of  pus. 

A  very  short  experience  with  debridement 
in  compound  fractures  demonstrated  that  the 
bruising  and  laceration  of  soft  parts  extend  far 
beyond  limits  hitherto  suspected.  Excision 
must,  therefore,  be  even  more  extensive  than 
in  simple  wounds.  Loose  bone  fragments, 
often  driven  very  far  indeed,  are  to  be  carefully 
sought  and  removed  but  no  fragment  that  is  at- 
tached to  viable  periosteum  or  muscle  should 
ever  be  sacrificed.  A  favorite  site  for  small 
loose  splinters  is  the  exposed  marrow.  The 
medullary  canals  should  anyway  be  thoroughly 
curetted  for  a  depth  of  about  three  quarters  of 
an  inch,  as  it  is  into  this  soft  cancellous  bone 
that  infectious  matter  is  frequently  driven.  So 
essential  is  this  curettement  that  it  is  to  be  done 
even  at  the  expense  of  removing  a  healthy  frag- 
ment that  blocks  approach  to  the  marrow. 
Often,  however,  such  viable  fragments  can  be 
preserved  by  carefully  cutting  and  lifting  the 
binding  periosteum  along  one  side,  using  that 
on  the  other  as  a  hinge  that  will  preserve  its 
nutrition.  As  for  the  internal  fixation  of  bone 
ends,   that   is   rarely   indicated   at   the   primary 


46 

operation  and  when  done  only  the  simplest  and 
quickest  methods  are  permissible.  Plates  of 
foreign  material  and  autogenous  bone  grafts 
have  proved  useless,  even  harmful,  at  this  stage 
of  the  treatment.  On  the  other  hand  it  is  most 
important  to  mold  all  the  comminuted  frag- 
ments into  a  compact  mass  that  fills  the  de- 
ficiency between  the  main  fragments ;  it  is  even 
permissible,  when  necessary,  to  hold  the  mass 
in  position  by  deftly  placed  sutures  in  surround- 
ing muscles.  Last  and  of  the  utmost  importance 
is  complete  hemostasis,  for  nowhere  as  in  bone 
does  blood  clot  so  encourage  infection. 

With  the  attainment  of  hemostasis  the  analogy 
between  the  treatments  of  simple  wounds  and 
compound  fractures  abruptly  ends.  Even  in  the 
eight  to  ten  hour  period  primary  closure  of 
compound  fractures  proved  most  disappointing. 
It  may  be  that  the  virulent  bacteria  of  the  war 
zone  account  for  failures  that  would  not  ob- 
tain in  civil  life ;  it  may  be  that  the  extensive 
comminution  of  bone  incident  to  war  wounds 
and  less  often  encountered  elsewhere  is  the  ex- 
planation ;  it  may  be  any  one  or  any  combina- 
tion of  many  other  possible  factors  that  is  at 
fault :  but  the  fact  remains  that  in  the  recent 
war  primary  suture  of  compound  fractures  so 
often  and  disastrously  failed  that  the  attempt 
was  pretty  generally  abandoned.  Further  ex- 
perience, however,  demonstrated  that  the  bone 
involved  had  an  important  bearing;  for  it  was 
learned  that  compound  fractures  of  the  clavicle, 
ulna,   and   radius   could   be   closed   by   primary- 


suture  not  only  with  an  even  chance  of  success 
but  also  without  jeopardizing  life  or  limb. 
Whether  or  not  this  limitation  to  primary 
closure  is  going  to  obtain  in  civil  life  can  be 
answered  only  by  further  experience  under  cir- 
cumstances less  harrowing  than  those  prevalent 
on  the  battle  field. 

Delayed  primary  suture  proved  equally  dis- 
appointing. There  was,  then,  nothing  to  do  but 
to  leave  the  wounds  wide  open  and  to  pin  entire 
faith  on  chemical  sterilization,  the  original  prin- 
ciple whose  successful  application  had  embold- 
ened pioneers  to  develop  and  perfect  the  early 
closure  of  wounds.  The  faith  was  not  mis- 
placed. In  no  other  class  of  cases  have  the  re- 
sults of  Carrel-Dakin  technique  proved  so  bril- 
liant. Fresh  compound  fractures,  that  is  those 
received  within  twenty-four  hours,  can  be  com- 
pletely sterilized  in  from  three  to  four  weeks 
when  secondary  closure  will  succeed  in  a  good 
majority  of  the  cases.  This  is  indeed  a  marvel- 
ous achievement  to  be  fully  appreciated  only 
when  compared  with  the  weeks  and  months  of 
septic  course  that  compound  fractures  often 
used  to  follow  only  to  end  in  a  chronic  condi- 
tion that  sometimes  never  healed.  It  is  freely 
admitted  that  the  good  surgery  practiced  is  the 
indispensable  fore-runner  of  the  success  of  the 
sodium  hypochlorite  solution,  but  good  surgery 
is  also  part  and  parcel  of  the  Carrel-Dakin 
treatment  constantly  emphasized  by  its  authors, 
so  that  no  credit  is  to  be  withdrawn  from  its 
originators  on  that  score.    Furthermore,  equally 


48 

good  surgery  followed  by  other  technique  has 
never  in  compound  fractures  also  equalled  the 
success  obtained  with  Dakin's  solution.  Con- 
tinuous immobilization  and  extension  is  of 
course  absolutely  essential.  The  standardized 
splints  easily  lend  themselves  to  the  require- 
ments of  Carrel-Dakin  technique,  nor  do  they 
in  the  least  hinder  or  obstruct  subsequent  dress- 
ings. Extension  by  means  of  adhesive  plaster 
has  been  superseded  by  equally  efficient  glues, 
such  as  Sinclair's.'^  This  glue  melts  at  a  tem- 
perature that  does  not  burn  skin,  is  easy  and 
cheap  to  make,  does  not  require  shaving  of  the 
part,  and  of  the  greatest  importance  does  not 
macerate  the  integument.  It  is  applied  hot  with 
a  paint  brush  stroked  against  the  growth  of 
hair.  A  strip  of  folded  gauze  or  muslin  is  laid 
on  the  soft  glue  and  smeared  to  the  skin  with 
a  few  strokes  of  the  brush.  The  glue  hardens 
smooth  in  about  twenty  minutes  when  it  is 
capable  of  withstanding  considerable  steady 
pull. 

Osteomyelitis. 

In  spite  of  painstaking  treatment  some  fresh 
compound  fractures  yielded  to  infection  that, 
successfully  driven  from  soft  parts,  became 
firmly  seated  in  the  more  vulnerable  bone.  Al- 
most   without    exception    cases    neglected    from 

'Sinclair's  Glue. 

Ordinary  white  glue   50  parts. 

Water 50      " 

Glycerin    2      " 

Calcium  chloride   2      " 

Th>-mol    1      " 


49 


any  cause  developed  bone  infection  of  varying 
severity.  The  result  was  a  vast  collection  of 
cases  of  chronic  osteomyelitis  whose  prolonged 
course  crowded  the  hospitals  with  a  most  dis- 
couraging amount  of  sepsis.  Cases  were 
operated  time  and  time  again  only  to  be  fol- 
lowed by  the  formation  of  persistently  discharg- 
ing sinuses.  Much  of  the  surgery  failed  be- 
cause it  was  ill-timed.  Experience  established 
two  dangerous  periods  in  the  course  of  com- 
pound fractures  when  operative  interference  is 
not  only  futile  but  harmful:  first  during  the 
phase  of  acute  phlegmon;  and  second  at  the 
time  of  union.  Cases  of  non-union  should  be 
left  alone  eight  to  ten  weeks.  Even  with  the 
avoidance  of  these  two  fateful  periods,  how- 
ever, surgery  was  discouraging  until  the  Car- 
rel-Dakin  technique  was  perfected.  The  results 
then  obtained  far  surpassed  in  brilliancy  any- 
thing yet  accomplished  by  that  means,  because 
it  offered  a  certainty  of  cure  for  a  condition 
otherwise  chronically  hopeless.  While  much  of 
the  credit  reverts  again  to  the  solution  of  sodium 
hypochlorite,  the  recognition  and  application  of 
a  surgical  principle  is  equally  meritorious. 
Cavities  heal  by  the  collapse  and  consequent  op- 
position of  their  walls.  Cavities  in  bone,  which 
are  the  essential  cause  of  the  perpetuation  of 
osteomyelitis,  cannot  heal  because  their  walls 
are  rigid  and  cannot  collapse.  Therefore,  the 
cavities  must  be  obliterated.  When  this  is  ac- 
complished by  the  bold  removal  of  irregularities 
of    the   walls,    and    over-hanging   bone,   healing 


50 


occurs.  A  bottle  shaped  cavity  in  bone  never 
heals.  No  adequate  treatment  of  bone  cavity 
analogous  to  the  dentist's  management  of  a 
tooth  cavity  has  yet  been  devolved.  The  only 
successful  procedure  so  far  found  is  the  con- 
version of  the  deep,  narrow,  irregiilar  cavity 
into  a  wide,  shallow,  smooth,  saucer-shaped 
area  to  be  subsequently  bathed  with  Dakin's 
solution.  Tunnel  cavities  through  bone  will  not 
close  until  either  the  roof,  floor,  or  one  side  of 
the  tunnel  is  excised.  Seemingly  excessive 
amounts  of  inherently  healthy  bone  have  to  be 
sacrificed,  but  there  is  no  other  way.  Not  a 
small  factor  in  the  success  of  this  extensive 
osseous  debridement  is  the  removal  of  occult 
bone  areas  potentially  liable  to  necrosis  and 
sequestration.  It  is  surprising  how  quickly 
these  large  cavities  fill.  Granulations  grow 
rapidly  from  adjacent  muscle  and  other  soft 
tissue ;  skin  quickly  epidermizes  over  them ; 
osteoblasts  invade  them  and  form  new  bone ; 
and  in  time  the  primary  depression  in  the  con- 
tour of  the  bone  becomes  leveled.  Perfect  im- 
mobilization of  the  wound  must  be  constantly 
maintained  until  healing  is  fully  completed. 

Face  and  Jaw  Wounds. 

Of  not  unusual  occurrence  were  most  dis- 
tressing wounds  of  the  facial  and  jaw  bones 
that  attracted  particular  attention,  not  only  on 
account  of  the  sometimes  hideous  disfigurement 
they  caused,  but  also  on  account  of  the  difficulty 
of   dealing  with  them.     The  difficulty  was  the 


51 


natural  outcome  of  an  attitude  that  contemplated 
dentistry  and  surgery  as  two  distinct  and 
separate  professions.  This  feeling  the  war 
abolished.  It  is  now  an  axiom  that  wounds  in- 
volving the  jaws  and  adjacent  soft  parts  are  to 
be  treated  concurrently  and  cooperatively  by 
dentist  and  surgeon,  not  as  formerly  independ- 
ently and  in  sequence. 

The  blood  supply  of  the  face  is  so  good  that 
the  eight  to  ten  hour  limit  for  primary  closure 
can  be  safely  extended  to  twenty-four  hours. 
While  infection  in  wounds  of  this  region  is 
common,  perhaps  constant,  it  is  never  alarm- 
ing, and  anaerobic  infection  is  unknown.  Tem- 
porary immobilization  should  be  secured  im- 
mediately and  permanent  splinting  as  soon  as 
infection  is  localized  or  under  control,  and  while 
the  bone  fragments  are  still  mobile.  Great  in- 
genuity is  required  for  each  case  is  a  separate 
problem.  The  constant  aim  should  be  to  pre- 
vent disfigurement  by  preserving  the  normal 
contour  of  the  face ;  and  to  provide  good  dental 
occlusion  by  proper  alignment  of  fragments. 
Spontaneous  union  by  filling  in  can  be  confi- 
dently expected  when  the  loss  of  bone  does  not 
exceed  half  an  inch ;  and  is  not  impossible  where 
the  loss  is  as  much  as  three-quarters  of  an  inch. 
More  than  that  requires  bone  grafting.  The 
callus  can,  however,  be  considerably  stretched 
during  its  formation,  but  must  be  done  very 
gradually,  so  that  it  is,  therefore,  rarely  neces- 
sary to  sacrifice  contour  or  occlusion  for  the 
sake  of  union. 


52 


Besides  the  control  of  hemorrhage  and  infec- 
tion, which  is  perhaps  the  sole  province  of  the 
surgeon,  there  is  anatomic  restoration,  the  par- 
ticular job  of  the  dentist.  All  three  can  and 
should  be  handled  simultaneously.  Dental 
prosthetic  appliances  are  numerous  and  many 
of  them  predicate  special  training  for  their  ap- 
plication. The  temporary  splints,  however,  are 
simple  and  their  use  easily  mastered.  If  the 
upper  jaw  is  intact  a  very  efficient  temporary 
splint  is  made  by  putting  modelling  composi- 
tion between  the  teeth,  pushing  the  lower  jaw 
up  into  it  in  nice  occlusion  and  holding  it  there 
by  a  chin  cup.  The  composition  rapidly  hardens 
and  preserves  the  reduction.  At  the  best,  how- 
ever, it  is  but  a  crude  makeshift  to  be  used  only 
in  emergencies ;  for  it  allows  neither  adequate 
breathing  space  nor  room  for  subsequent 
swelling  of  the  parts.  A  far  better  device  is 
the  Gunning  stock  dental  splint  of  aluminum. 
It  consists  of  an  upper  and  a  lower  cup,  each 
filled  with  modelling  composition  and  so  hinged 
with  its  fellow  as  to  simulate  normal  vertical 
jaw  movements.  The  teeth  are  forced  into  the 
respective  cups  in  a  restored  position,  the  jaws 
brought  as  near  together  as  the  splint  permits, 
and  a  chin  cup  added.  The  Gunning  splint  has 
all  the  advantages  of  modelling  composition 
alone,  is  standardized,  cheap,  and  portable,  and 
has  the  desirable  additional  feature  of  fixing  the 
mouth  open.  Modifications  of  the  above  with 
outside  attachments  to  fit  individual  cases,  and 
intermaxillary  fixation  by  direct  wiring,  belong 


53 


exclusively  to  the  dentist.  The  same  is  true  of 
the  ingenious  use  of  minute  jack-screws  which 
turn  by  turn  gradually  stretch  the  growing 
callus  and  further  restore  normal  contour.  On 
the  other  hand  bone  grafting  falls  properly  to 
the  surgeon.  The  best  grafts  are  obtained  from 
the  nearer  clavicle  and  are  transferred  by  a  two 
stage  operation.  The  graft  is  cut  and  one  end 
transferred  to  its  new  site  leaving  the  other  end 
as  a  pedicle  attached  by  the  sterno-mastoid 
muscle.  At  the  end  of  ten  days  when  the 
pedunculated  graft  has  established  'circulation 
from  its  new  insertion,  the  pedicle  is  cut  and 
the  graft  swung  into  place.  With  its  vitality  in 
its  new  site  assured  the  graft  can  be  then  so 
molded  by  the  dentist  with  his  interdental 
splints  or  direct  wiring  as  to  correct  possible 
defects  of  contour  or  errors  of  occlusion. 

Septic  Joints. 

Nowhere  perhaps  in  the  body  has  infection 
been  harder  to  deal  with  than  in  joints.  For 
years  septic  arthritis  has  freely  travelled  a  most 
destructive  course  leaving  in  its  wake  com- 
pletely disorganized  joints,  often  with  persist- 
ently discharging  sinuses,  inevitably  with 
ankylosis,  partial  or  complete.  The  classical 
operation  of  wide  incision  and  free  drainage  did 
not  in  the  least  alter  the  course  of  things,  except 
to  save  life.  The  certain  end  results  were  per- 
manently impaired,  often  nearly  useless,  limbs 
which  the  unfortunate  possessors  of  at  last 
sacrificed    most    willingly.      Early    in    the    war, 


54 


therefore,  wounded  joints,  because  of  their  cer- 
tainty of  infection,  presented  such  horrible 
problems  that  it  is  not  perhaps  surprising  that 
premature  amputation  was  often  advised  with 
the  assurance  that  if  accepted  months  of  suf- 
fering and  an  eventually  disabled  limb  would 
be  avoided.  Before  the  war  a  bold  pioneer  here 
and  there  had  advocated  as  a  substitute  for  in- 
cision and  drainage  thorough  chemical  cleansing 
of  the  opened  joint  which  was  to  be  closed  im- 
mediately by  suture.  To  the  conservative  sur- 
geon the  procedure  savored  of  such  extreme 
radicalism  that  it  was  frowned  upon  and  gen- 
erally ignored.  Given  free  opportunity,  how- 
ever, with  the  many  joint  wounds  incident  to 
the  war  progressive  surgeons  succeeded  in 
demonstrating  that  the  idea  of  closing  wounded 
joints  was  practical.  From  their  bold  enter- 
prising work  it  has  been  proved  that  synovial 
membrane  is  itself  markedly  resistant  to  infec- 
tion and  fully  able  to  take  care  of  a  not  incon- 
siderable amount  without  damage  to  itself.  It 
is  the  capsule  of  the  joint  and  the  extra-ar- 
ticular tissues  that  are  vulnerable  and  to  be 
feared.  The  fate  of  a  wounded  joint  depends, 
therefore,  upon  the  success  with  which  wounds 
of  the  soft  parts  surrounding  the  articulation 
are  treated. 

Small  perforating  wounds  without  fracture 
generally  heal  promptly  under  simply  compres- 
sion and  immobilization ;  more  extensive 
wounds  can  be  treated  according  to  the  rules 
already   laid    down.     Within   the    eight   to   ten- 


55 

hour  period  careful  debridement  of  periar- 
ticular tissues  and  synovia,  removal  of  foreign 
bodies,  and  thorough  irrigation  of  the  joint  with 
mild  antiseptic  solution,  can  be  followed  by 
primary  suture.  Thereafter  extension,  im- 
mobilization, and  a  stern  attitude  of  non-inter- 
ference will  bring  about  first  intention  healing 
in  about  90%  of  the  cases.  Beyond  the  eight 
to  ten  hour  period,  and  even  when  obviously 
septic,  joint  wounds  should  be  excised,  irrigated, 
and  the  synovia  closed  immediately  by  suture 
but  with  drainage  of  extra-articular  tissues 
down  to  the  synovia.  Under  such  treatment  it 
is  surprising  how  quickly  and  completely  in 
many  instances  the  signs  of  intra-articular  in- 
fection subside  and  how  good  a  functional  joint 
results.  Long  standing  septic  joints  are  of 
course  another  matter.  Here,  not  only  has  the 
synovia  been  destroyed,  but  the  joint  cartilages 
have  been  eroded  and  the  peri-articular  struc- 
tures thickened  and  deformed.  Incision  and 
drainage  result  only  in  endless  discharge  and  a 
useless  limb.  Resections  have  not  effected 
quick  subsidence  of  sepsis  nor  favored  bony 
union.  On  the  whole  amputation,  as  soon  as 
the  case  is  deemed  hopeless,  gives  the  lowest 
mortality,  the  shortest  convalescence,  and  the 
best  satisfied  patient.  The  method  devised  by 
Speed  of  subcrural  drainage  of  the  knee  joint 
by  a  tube  in  the  upper  end  of  the  pouch,  the 
leg  in  extension  in  a  Thomas  splint  and  slung 
from  a  Balkan  frame,  turning  the  patient  on 
his  face  for  two  hours  twice  a  day,  is  worthy 


56 


of   further  trial,  and  may  be   found  to  be  the 
means  of  saving  otherwise  hopeless  leg^s. 

With  eventual  ankylosis  certain  because  of  the 
severe  nature  of  the  injury,  sepsis,  or  what  not, 
it  is  imperative  that  ankylosis  be  obtained  in  the 
position  of  greatest  usefulness.  In  the  shoulder 
the  humerus  should  be  so  placed  that  its  axis 
makes  an  angle  of  seventy  degrees  with  the  ver- 
tebral border  of  the  scapula.  In  the  elbow  a 
position  of  no  degrees  is  the  angle  of  choice. 
The  knee  should  be  very  slightly  flexed. 

Amputations. 
Due  entirely  to  the  marvelously  improved 
methods  of  treating  and  controlling  severe  in- 
fections, the  indications  for  amputation  have 
themselves  been  amputated  one  by  one.  Limbs 
that  heretofore  were  deemed  hopeless  can  now 
be  saved.  More  and  more  should  this  idea  be  en- 
couraged and  tentative  attempts  made  to  save 
every  limb  ;1  for  the  Carrel-Dakin  technique  of- 
fers positive  means  of  preserving  tissues  that 
were  formerly  lost.  Next  to  severity  of  injury 
and  virulence  of  gross  infection,  the  tourniquet 
is  directly  responsible  for  most  amputations. 
Eighty  per  cent,  of  wounds  whose  blood  supply 
has  been  cut  of¥  by  tourniquets  for  a  period  of 
three  consecutive  hours  eventually  come  to  am- 
putation. If  a  tourniquet  must  be  used,  place 
it  always  justi  above  the  wound  in  order  that  as 
few  distal  segments  of  the  limb  as  possible  may 
be  deprived  of  blood.  Then  in  the  event  of 
later  imperative  amputation  section  may  be  made 


57 


just  above  the  line  of  the  tourniquet  and  several 
inches  of  Hnlb  that  would  otherwise  have  suf- 
fered from  a  higher  placed  tourniquet  can.  be 
saved. 

Stress  is  now  laid  notj  so  much  on  the  indi- 
cations for  amputation  as  on  the  kind  of  ampu- 
tation indicated.  The  early  struggles  with  gross- 
ly and  virulently  infected  limbs,  shattered  be- 
yond all  hope,  taught  through  the  occurrence 
of  continued  sepsis  in  the  stumps  that  the  guillo- 
tine operation  still  really  occupies  a  place  in 
surgery.  Though  it  results  in  a  poor  stump, 
almost  impossible  in  the'  lower  limbs,  a  poor 
stump  on  a  live  patient  is  far  preferable  to  a 
good  stump  on  a  dead  one.  In  other  words  the 
guillotine  operation  is  solely  a  life  saving  meas- 
ure. Even  when  healing  is  complete  such  stumps 
are  impossible  to  fit  satisfactorily  with  a  pros- 
thesis ;  and  in  the  lower  limbs  where  the  stumps 
must  bear  weight  the  circular  amputation  seldom 
allows  weight  bearing  because  the  scar  crosses 
the  end.  Whenever,  therefore,  the  guillotine 
operation  is  performed  it  must  be  with  the  ex- 
pectation that  later  on  recourse  will  be  had  to 
a  secondary,  amputation.  There  is,  however, 
this  specific  exception:  if  the  secondary  opera- 
tion will  convert  a  healed  circular  amputation 
in  the  middle  third  of  the  thigh  into  one  in  the 
upper  third,  it  is  preferable  for  prosthetic  rea- 
sons not  to  re-amputate  but  to  preserve  the 
extra  length  of  femur  with  an  imperfect  stump. 
All  circular  amputation  stumps  are  to  be  left 
wide  open  and  subsequently  treated  either  ac- 


58 


cording  to  the  rules  of  delayed  primary  suture 
or,  after  sterilization  by  Carrell-Dakin  tech- 
nique, on  the  principle  of  secondary  closure. 

The  management  of  bone  ends  has  undergone 
radical  changes  through  a  correct  appreciation 
of  the  role  played  by  the  periosteum  and  ex- 
posed marrow.  These  structures  have  been 
proved  to  be  the  guilty  cause  of  those  painful 
stumps  that  are  accompanied  by  an  over-growth 
of  bone.  The  old  theory  that  these  tissues  must 
be  preserved  is,  therefore,  no  longer*  tenable. 
Instead,  the  entire  circle  of  periosteum  must  be 
thoroughly  scraped  away  from  the  bone  end  for 
a  space  of  one  to  two  centimeters,  and  the  mar- 
row curetted  an  equal  distance.  Rarely  indeed 
does  the  compact  bone  so  exposed  suffer  from 
lack  of  nutrition  as  evidenced  by  the  later  for- 
mation of  sequestra  which  demand  removal.  On 
the  other  hand,  painful  stumps  from  exuberant 
osseous  growth  are  absolutely  prevented. 

In  general  it  should  be  a  fixed  rule  to  save 
every  inch  of  limb  possible.  This  is  always 
feasible  in  the  upper  extremities  where  the  kind 
of  operation  indicated  should  be  that  which  pre- 
serves the  longest  stump.  So  great  have  been 
the  improvements  in  prosthetic  appliances  that 
the  loss  of  an  inch  from  the  stump  to  be  fitted 
may  fatally  preclude  the  enjoyment  of  an  artifi- 
cial arm  whose  dexterous  mechanical  features 
depend  entirely  on  that  sacrificed  inch.  More- 
over, every  bit  of  muscle  and  tendon  that  can 
be  preserved  around  the  stump  is  of  inestimable 
value.     Very  ingenious  plastic  operations  have 


59 

been  devised  which  make  use  of  these  muscles 
and  tendons  to  activate  by  voluntary  contrac- 
tion the  inanimiate  fingers  of  a  false  hand. 

In  the  lower  limbs,  on  the  contrary,  the  goal 
aimed  at  is  a  good  weight  bearing  stump.  To 
this  end  sacrifices  in  the  length  of  bone  and  in 
the  mass  of  muscles  and  tendons,  blameworthy 
procedures  in  the  upper  extremities,  are  often 
justified  in  the  lower  limbs  for  the  sake  of 
better  weight  bearing  attainment.  End  bearing 
stumps  are  to  be  preferred  because  they  pre- 
serve some  sense  at  least  of  ground  feeling. 
Emergency  guillotine  I  operations  should  be, 
therefore,  so  planned  that  at  the  secondary  am- 
putations end  bearing  stumps  can  be  constructed 
without  undue  sacrifice  of  tissue.  The  old 
points  of  election  for  amputation  have  to  a  large 
extent  lost  favor  which  now  redounds  to  con- 
siderations of  usefulness  and  weight  bearing. 
The  attention  paid  to  anatomical  limitations  is 
no  longer  positive  but  \  negative ;  useful  and 
weight  bearing  stumps  are  possible  at  nearly 
all  levels  except  as  a  general  rule  through  joints 
or  close  above  them.  In  the  foot,  however, 
Syme's  amputation  has  returned  into  vogue  pro- 
vided the  articular  surface  of  the  tibia  is  pre- 
served and  the  malleoli  are  shaved  off  laterally. 

Surgical  Shock. 

In  spite  of  the  unparalleled  opportunities  for 
observation  and'  study  of  surgical  shock  that 
the  war  so  generously  supplied,  the  cause  of 
the   affection   remains   in   darkness.     Old    facts 


60 


regardinj;^  its  phenomena  have  been  amply  con- 
firmed and  emphasized,  and  empirical  methods 
of  treatment  to  correct  the  symptom  or  syn- 
drome that  most  appealed  to  individual  investi- 
gators as  the  dominating  feature,  have  been  en- 
thusiastically promulgated  with  varying  degrees 
of  success.  Some  of  these  are  not  even  new 
but  merely  resurrected  from  a  forgotten  past. 
To  reiterate,  for  example,  that  the  fundamental 
trouble  in  shock  is  loss  of  blood  plasma  into 
the  tissues  is  a  wearisome,  hackneyed  statement 
that  means  nothing.  Admirable  as  are  the  re- 
ports of  special  commissions  in  restating  and 
correlating  the  facts,  they  offer  nothing  funda- 
mentally new.  Unfortunately  lack  of  confirma- 
tion, not  infrequently  amounting  to  actual  dis- 
agreement, but  further  befogs  the  main  issue. 
On  the  whole,  considering  the  mass  of  available 
material  for  study  the  total  results  are  keenly 
disappointing. 

However  that  may  be,  the  knowledge  gained 
is  not  entirely  negligible.  The  enormous  num- 
ber of  shock  cases  that  occurred  gave  an  un- 
rivaled opportunity  for  investigation ;  and  the 
frightful  mortality  from  that  cause  alone  added 
a  stimulus  to  endeavor  that  was  bound  to  be  pro- 
ductive of  something.  The  attack  on  the  prob- 
lem was  made  in  what  proved  to  be  the  ideal 
way.  Special  shock  teams  were  organized  and 
equipped  to  deal  specifically  with  shock  cases. 
Near  the  operating  theatres  rooms  were  set 
aside  for  the  exclusive  use  or  these  teams,  whose 
almost  instant  results   fully  justified  their  con- 


61 

ception.  It  was  not  that  new  specific  remedies 
were  suddenly  and  miraculously  discovered,  but 
simply  that  by  intensive  study  and  observation 
old  facts  reg^ardinj2^  shock  were  correctly  cor- 
related and  well-founded  principles  of  treat- 
ment were  deftly  applied  by  new  ingenious 
means  which  proved  to  be  more  potent. 

Two  distinct  types  of  surgical  shock  are  now 
well  defined.  The  first  is  styled  acute.  It  de- 
velops very  quickly  in  men  whose  wounds  are 
so  trivial  and  whose  exposure  to  the  other  usual 
causative  agents  is  so  fleeting  and  mild  as  to 
be  negligible  factors  in  its  production,  that  it 
can  be  explained  only  by  tlie  highly  organized 
nervous  temperament  which  such  cases  univer- 
sally exhibit.  It  has  been  not  unfavorably  com- 
pared to  ordinary  syncope.  It  is,  however,  a 
serious  condition,  often  becoming  critical,  oc- 
cassionally  even  fatal,  without  prompt  and  en- 
ergetic attention  which  as  in  syncope  is  generally 
fruitful.  The  second  type  is  the  more  familiar 
one  of  slower  and  more  insidious  development 
that  aggravates  severe  bodily  injury  and  is  often 
fatally  progressive  in  spite  of  every  treatment. 
This  is  the  kind  of  shock  most  frequently  en- 
countered, constituting  the  classical  syndrome 
whose  etiology  is  obscure  and  many  of  whose 
phenomena  are  imperfectly  explained. 

The  influences  of  fatigue  and  cold  on  the  pro- 
duction and  aggravation  of  shock  have  long  been 
recognized,  but  probably  never  so  fully  appre- 
ciated as  now.  So  important  have  these  causa- 
tive    or    at    least    contributary,     factors    been 


62 


proved  to  I)e  that  it  must  be  forcibly  emphasized 
that  it  is  impossible  accurately  to  estimate  the 
true  condition  of  a  shocked  patient  until  he  has 
been  rested  and  warmed.  Fati^e  cannot  like 
cold  be  measured  clinically,  but  if  it  is  at 
all  commensurate  with  the  degree  of  cold  ob- 
served in  shock  it  must  often  be  extreme.  Low 
temperatures,  even  below  ninety-two  degrees, 
the  lowest  mark  on  the  common  clinical  ther- 
mometer, were  not  at  all  unusual;  and  following 
shocking  injuries  to  the  sixth,  seventh,  and 
eighth  cervical  segments  of  the  cord  readings  as 
low  as  eighty  degrees  were  found.  Fatigue  and 
refrigeration  are  factors  whose  influence  is  not 
only  sufficient  to  mask  the  real  state  of  the  vaso- 
motor system,  but  is  also  capable  of  so  aggra- 
vating its  failing  powers  from  other  causes  as  to 
bring  about  a  fatal  issue.  Whether  cold  and 
fatigue  are  cause  or  effect  is  beside  the  question  ; 
they  are  universally  present  in  shock  and  by 
their  presence  aggravate  the  shock.  In  this  con- 
nection it  must  not  be  forgotten  that  the  sum- 
mation of  painful  and  emotional  stimuli  pro- 
duces a  state  of  fatigue  as  surely  as  does  mus- 
cular exertion,  and  more  perniciously.  It  has  to 
be  granted,  therefore,  that  shocked  patients  are 
cold  and  tired,  and  such  being  the  case  it  be- 
hooves surgeons  not  to  size  up  things  too  rashly. 
These  factors,  moreover,  can  deceive  in  both 
directions ;  they  may  temporarily  be  the  dominat- 
ing causes  and  as  such  make  a  case  appear  worse 
than  it  really  is ;  or  through  delay  in  the  full  dis- 
closure of  their  sinister  potentialities  they  may 


63 


fail  to  refute  a  false  sense  of  optimism  wholly 
justified  by  the  meagreness  of  other  causative 
agents.  The  safe  course  lies  somewhere  be- 
tween impatience  and  procrastination. 

The  most  reliable  measure  of  the  degree  of 
shock  as  well  as  the  most  accurate  guide  in 
prognosis  is  frequently  repeated  sphygmogra- 
phic  determinations,  more  specifically,  diastolic 
readings.  Blood  pressure  observations  have  ab- 
solute as  well  as  relative  values.  A  diastolic 
level  of  60  mm.  is  the  critical  level ;  below  50 
mm.,  fatal.  A  low  diastolic  pressure  accompany- 
ing a  systolic  as  high  even  as  100  mm.  invaria- 
bly affirms  shock.  If  the  diastolic  reading  fails 
to  rise  with  appropriate  treatment,  irrespective" 
of  systolic  behavior,  the  case  is  hopeless.  The 
longer  blood  pressure  remains  low  the  more  dif- 
ficult becomes  the  matter  of  resuscitation ;  the 
more  profound  are  the  metabolic  changes  of 
reduction  of  alkali  reserve  and  acidosis ;  the 
more  unlikely  is  the  eradication  of  the  effect  of 
these  plus  the  original  shock;  and  the  more  ar- 
duous is  the  restoration  of  equilibrium  and  con- 
trol of  the  nervous  system. 

There  is  still  no  specific  remedy  to  prevent  or 
combat  shock  and  there  will  not  be  until  the 
fundamental  cause  of  the  condition  is  learned. 
The  nearest  approach  to  specific  treatment, 
whether  the  shock  is  due  to  hemorrhage  or  not, 
is  blood  transfusion  from  suitable  donors. 
Transfusion  by  any  proved  method  after  cor- 
rect typing  of  donor  and  recipient  is  very  rarely 
indeed  accompanied  by  danger  in  the  hands  of 


64 


competent  operators.  Its  efficacy  is  not  only  un- 
cjuestioned,  but  its  advantajres  are  far  superior 
to  all  other  methods  of  restoring  fluid  to  the 
vessels.  Intravenous  salt  solution  so  quickly 
escapes  back  into  the  tissues  that  its  action  is 
very  fleeting.  Acacia,  gelatine,  and  other  col- 
loid solutions  compounded  to  correct  this  fault 
are  not  without  danger  and  fail  to  remain  in 
the  vessels.  The  serious  objection  to  transfu- 
sion that  it  is  often  difficult  to  obtain  a  suitable 
donor  on  the  spur  of  the  moment  has  been  met 
by  the  discovery  that  blood  corpuscles  may  be 
preserved  in  dextrose  and  stored  on  ice  for  as 
long  as  a  month  without  losing  their  viability. 
Transfusion  with  stored  blood  has  achieved  re- 
sults as  good  as  those  from  fresh  blood,  and  is 
without  additional  danger. 

Many  methods  of  treatment  may  perhaps  be 
specific  in  the  sense  that  they  are  such  against 
one  phenomenon  alone.  The  fault  with  each  of 
such  remedies  is  that  it  postulates  a  single  symp- 
tom as  the  primary  and  controlling  factor  whose 
successful  elimination  cures  shock.  These 
methods  of  treatment  are  based  many  timtes  on 
purely  theoretical  premises,  propped  up  by  posi- 
tive but  incorrectly  interpreted  scientific  facts, 
and  exploited  by  empiricism.  Often  they  prove 
curative  only  in  the  hands  of  their  enthusiastic 
and  perhaps  biased  sponsors.  Sodium  bicarbo- 
nate administration,  for  example,  predicates  an 
acidosis  as  the  dominant  feature  which  is  by 
no  means  proved  or  generally  accepted.  Acido- 
sis is  best  to  be  viewed  not  as  alwavs  a  causa- 


65 


live  factor  nor  as  always  tlie  chief  phenomenon, 
but  is  rather  to  be  construed  as  only  one  of 
many  frequent  associated  changes  due  to  an  un- 
known primary  cause.  It  cannot  be  denied, 
however,  that  not  infrequently  bicarbonate  of 
soda  does  cause  improvement,  but  when  it  does 
so  the  case  is  best  regarded  as  one  in  which  for 
some  reason  acidosis  plays  a  prominent  part  and 
other  features  are  as  strangely  in  abeyance.  Its 
use  would  seem,  therefore,  to  be  restricted  ra- 
tionally to  those  cases  of  shock  evidencing  cer- 
tain or  impending  acidosis,  when  its  administra- 
tion assuredly  combats  so  much  of  the  effects  of 
shock  as  are  due  to  the  associated  acidosis.  The 
inhalation  of  carbon  dioxide,  either  as  pure 
gas  or  as  rebreathing  of  the  patient's  own  ex- 
pirations, is  an  accredited  remedy  based  on  the 
well  known  property  of  that  gas  to  stimulate 
deep  inspirations.  Shallow,  rapid,  ineffectual 
respiration  is  almost  universal  in  shock.  The 
diaphragm  therefore  fails  to  exert  its  full  power 
of  sucking  blood  into  the  right  heart.  The 
theory  is  that  under  carbon  dioxide  stimulation 
the  excursion  of  the  diaphragm  is  increased,  a 
higher  negative  pressure  is  created  in  the  thorax, 
and  blood  is  thereby  aspirated  from  the  venous 
and  capillary  systems  and  returned  to  active 
circulation  which  corrects  the  fundamental  fault. 
Whether  or  not  it  works  out  according  to  this 
theory,  the  fact  remains  that  the  method  has 
produced  some  very  startling  results  and  de- 
serves further  trial. 
When  all  is  said  and  done,  however,  it  is  the 


66 


common  sense  measures  based  on  well  proven 
facts  that  are  most  reliable.  Once  the  true  por- 
tent of  the  deleterious  factors  of  fatigue  and 
cold  was  correctly  appreciated  measures  that 
would  ably  combat  their  dire  influences  were 
sought  and  instituted.  The  causes  of  fatigue  in 
its  widest  sense  are  manifold,  and  are  both 
physical  and  emotional.  A  certain  degree  of 
bodily  weariness  and  mental  usury,  the  latter 
manifested  by  either  depression  or  excitement, 
was  a  constant  sequela  of  the  perilous  exigen- 
cies of  trench  life.  In  other  words  the  soil  was 
prepared  for  the  quick  production  of  fatigue. 
The  eftect  of  the  actual  physical  destruction  of 
tissue  was  rapidly  augmented  by  the  steady  flow 
of  pain  sensations  from  the  wound  and  the  ex- 
hausting play  of  the  suddenly  created  emotions 
of  fear,  grief,  and  the  like.  Hunger  and  thirst 
soon  added  their  quota  until  a  well  marked  de- 
gree of  mental  and  physical  exhaustion  was 
present.  The  obvious  antidote  was  prevention. 
The  wound  itself  must  be  spared  all  unneces- 
sary handling  and  put  definitely  at  rest  by 
proper,  splinting.  Rough  manipulation,  even 
with  the  laudable  purpose  of  restoring  anatomi- 
cal relations,  is  often  sufficient  to  shove  balanc- 
ing patients  over  the  threshold  into  severe  shock. 
Transportation  must  be  reduced  to  a  minimum. 
Even  a  comparatively  smooth  railway  journey 
has  a  bad  eftect.  It  was  early  noted,  for  ex- 
ample, that  a  man  with  a  compound  fracture  of 
the  femur  who  in  warm,  clear  weather  lived  in 
the   open    for   several   days   without   treatment, 


67 

reached  a  hospital  in  better  shape  as  regards 
shock  than  one  who  was  picked  up  and  moved 
without  delay.  Left  alone  the  wounded  man 
kept  his  leg  at  rest  and  thereby  warded  off 
or  recovered  from  his  shock.  Such  observa- 
tions as  these  warrant  close  attention  when 
other  considerations  compel  his  prompt  re- 
moval from  surroundings  bristling  with  other 
causative  agents.  Transportation  unavoid- 
ably provides  painful  stimuli  whose  sum- 
mation produces  fatigue  or  intensifies  beyond 
his  endurance  fatigue  already  present.  As 
some  transport  is  inevitable  the  rest  that  can- 
not be  assured  by  splints  and  posture  must 
be  invoked  by  the  free  use  of  sedatives.  Mor- 
phine is  the  drug  par  excellence  and  should 
be  given  in  half  grain  doses.  At  this  point 
it  must  be  sternly  emphasized  that  much  of 
the  benefit  from  morphine  is  dissipated  if  the 
patient  is  at  once  started  on  his  journey.  The 
administration  should  be  so  planned  that  a 
period  of  at  least  fifteen  minutes  be  provided 
for  the  injection  to  take  effect ;  otherwise  the 
premature  induction  of  painful  impulses 
breaks  down  the  half  made  sedative  barrier 
that  even  the  full  effect  of  morphine  is  unable 
later  to  close.  As  a  substitute  for  morphine 
a  British  preparation,  omnopon,  is  said  to 
have  about  two  thirds  the  sedative  power  of 
morphine  and  to  be  without  the  latter's  de- 
pressing eft'ect  on  metabolism  and  vital  nerve 
centers.  Duskiness  of  lips  and  finger  nails 
indicates  an   impairment  of  oxygenation.     It 


68 

may  be  due  entirely  to  the  deficient  respira- 
tion accompanying  shock,  but  not  always. 
Cyanosis  is  an  unmistakable  fore-runner  of 
acidosis,  which  must  be  construed  as  at  least 
an  associated  change  of  dire  potentialit}*. 
Morphine,  by  further  depressing  respiration, 
may  further  increase  cyanosis  and  hasten 
acidosis.  The  opposing  dangers,  therefore,  of 
pain  and  exhaustion,  cyanosis  and  acidosis, 
must  be  nicely  balanced  in  arriving  at  a  de- 
cision to  give  or  withhold  morphine. 

While  prompt  removal  from  places  of 
danger  where  fear  of  being  hit  again,  of  cap- 
ture, and  of  death  excite  a  rapid  play  of  ex- 
hausting emotions,  it  often  becomes  a  matter 
of  nice  judgment  to  decide  whether  or  not 
the  necessary  transportation  may  not  be  the 
greater  evil.  Morphine  is  indicated  in  either 
event,  in  order  to  blunt  these  emotions.  It  is 
agreeably  surprising  to  note  how  often  merely 
an  hour's  rest  changes  a  patient's  general  con- 
dition from  seeming  hopelessness  to  ability  to 
endure  transportation,  or  even  surgical  inter- 
vention, with  impunity. 

Equally  as  important  as  rest  is  the  preser- 
vation or  restoration  as  the  case  may  be  of 
normal  body  temperature.  Cold  is  not  only 
a  powerful  factor  in  the  production  of  shock 
but  it  always  appears  coincidently  with  the 
development  of  shock.  Unless  guarded 
against,  the  absolute  rest  demanded  will  in 
itself,  by  inhibiting  such  natural  safe-guards 
as  shivering  and   deep   breathing,   lower   still 


69 

further  the  body  temperature.     It  is  impera- 
tive, therefore,  that  heat  be  applied.     Many 
were  the  ingenious  methods  of  so  doing-  that 
were    under    the    spur    of    necessity    devised 
from    inadequate    materials.      It    makes    little 
difference  from  what  source  external  heat  is 
obtained,    but    it    must    be    constantly    remem- 
bered that  shocked  cases  are  less  sensitive  to 
heat   and    demand,   therefore,   greater   watch- 
fulness against  burns.     Internally  heat  is  sup- 
plied by  the  ingestion  of  hot  fluids,  nutritive 
if  possible.     In  this  connection  it  is  well  to 
bear  in  mind  that  shock  cases  are  very  fre- 
quently  nauseated   and   that   anything   intro- 
duced into  their  stomachs  may  easily  excite 
vomiting.     Not  only  is  coveted  heat  and  nu- 
trition   thereby    lost,    but    the    exertion    of 
vomiting   further   aggravates    existing   shock. 
On  the  whole  the  best  drink  is  tea  with  milk 
and    sugar,    a    combination    that   is    palatable 
and  much  more  often  retained  than  any  other. 
Measures   to   combat  fatigue   and   cold   must 
be  carried  out  simultaneously  and  not  in  se- 
quence,  otherwise   much   of  their   potency   is 
lost.     Vigorously  pursued  many  a  seemingly 
hopeless    case    has    been    revived    and    per- 
manently  restored   when   all   other   measures 
against    shock    were    unavailable.      Until    the 
primary  cause  of  shock  is  learned  and  a  ra- 
tional   specific    remedy    is    devised,    common 
sense   measures   offer   the   best   and   least   in- 
dispensible  methods  of  treatment. 


70 


Anesthesia. 
For    general    anesthesia    ether    has    ag^in 
been  proved  to  be  the  safest  agent.     The  open 
method   of    its   administration,    however,   was 
so  chilling  and   irritating  to  bronchi   already 
inflamed     by     the     cold     damp     air     of     the 
trenches  that  post-operative  pulmonary  com- 
plications   were    frequent.     The    substitution 
of   warmed    ether   vapor   by   closed    methods 
promptly  lessened  the  incidence  of  respiratory 
sequelae  and  came  to  be  generally  used.     A 
mixture  of  ether  and  chloroform  in  the  pro- 
portion of  sixteen  to  one  has  proved  a  pleas- 
ing   combination    preserving    the    safety    of 
ether,    devoid    of    the    inherent    dangers    of 
chloroform,   but   retaining  its   ease   of   induc- 
tion.    Stern   necessity  courted   the   invention 
of   simple   makeshifts  which   would   do   away 
with  the  expensive  and  complicated  apparatus 
devised  for  special  refinements  in  anesthesia, 
and  at  the  same  time  preserve  their  essential 
features.       A     rubber     tube,     for     example, 
slipped  over  the  spout  of  an  ordinary   ether 
can  and  connected  with  a  nasal,  pharyngeal, 
or  intratracheal  catheter,  was  a  most  simple 
expedient   that   gave   very   satisfactory   insuf- 
flation    anesthesia.       Air     entered     the     can 
through  perforations  in  the  top,  passed  over 
the   ether,   and   thence   was  aspirated   by   the 
patient's   own    inspiratory   exertions.      Gentle 
agitation  of  the  can  plus  the  warmth  of  the 
anesthetist's  hand  served  ably  to  concentrate 
ether  vapor   to   any   degree   required.      Doubt- 


71 


less  many  other  equally  simple  and  ingenious 
make-shifts  were  devised  by  men  whose  in- 
nate modesty  or  unobtrusiveness  has  tabooed 
publication   or   exploitation. 

Roentgenology. 

Forward  strides  in  the  field  of  roentgenology 
have  led  in  the  last  four  years  to  miraculous 
developments.  Without  these  remarkable 
advances  the  equally  astounding  achieve- 
ments in  surgery  would  have  been  greatly 
curtailed.  The  heretofore  immobility  of  the 
X-ray  plant  which  compelled  Mahomet  to 
come  to  the  mountain  has  all  been  changed. 
There  have  been  invented  easily  portable 
X-ray  outfits,  marvels  of  compactness,  light- 
ness, and  ease  of  adjustment,  whose  products 
at  least  equal  those  coming  from  their  im- 
mobile counterparts.  This  one  feature  of 
portability  has  put  at  the  free  disposal  of  sur- 
geons wherever  placed  an  indispensible  ad- 
junct to  their  art.  No  longer  must  patients 
forego  the  aid  of  roentgenology  because  their 
condition  is  so  critical  that  the  dangers  of 
transportation  ofifset  the  information  the 
X-ray  can  afford. 

Outside  of  other  improvements,  which, 
though  in  themselves  brilliant,  concern  really 
not  surgery  but  electrical  technique,  the  exact 
localization  of  foreign  bodies  in  three  planes 
constitutes  roentgenology's  greatest  offering. 
The  methods  devised  for  localization  can  in 
general  be  divided  into  two  distinct  groups: 


72 


the  first  localizes  a  foreign  body  by  a  depth 
measurement  in  a  vertical  direction  below  a 
skin  mark;  the  other,  in  addition  to  a  similar 
measurement,  supplies  also  a  surgical  indi- 
cator. Ever  since  roentgenologists  have  been 
induced  to  supplement  depth  measurement 
from  a  skin  mark  by  recording  also  the  rela- 
tion of  the  foreign  body  to  a  fixed  anatomical 
land-mark,  the  surgeon's  work  has  been 
greatly  facilitated.  As  an  example  of  the 
first,  measurement  only  group,  there  may  be 
mentioned  the  method  which  utilizes  the  prin- 
ciple of  the  parallax:  given  a  plane  surface, 
an  object,  and  a  movable  light,  the  movement 
of  the  object's  shadow  on  the  plane  surface 
will  be  proportionate  to  the  distance  of  the 
object  from  the  plane  surface.  With  two 
such  moving  shadows  the  shadow  of  the  ob- 
ject nearest  the  plane  surface  will  move  the 
more  slowly.  Using  the  foreign  body  to  cast 
one  shadow,  a  mobile  rod  on  the  apparatus 
is  adjusted  until  its  shadow  has  the  same  ex- 
cursion as  the  other.  From  a  scale  the  depth 
of  the  foreign  body  from  the  surface  is  com- 
puted and  marked  on  the  skin.  In  the  other 
group  the  Hirtz  compass  is  the  most  useful. 
This  is  an  ingenious  instrument  of  three 
parallel  legs  so  adjustable  to  the  irregular 
surface  of  the  body  that  the  base  of  the  in- 
strument preserves  its  level.  The  unique  fea- 
ture consists  of  an  adjustable  indicator  swung 
from  an  arc  that  is  firmly  attached  to  the  base 
of     the     instrument.      The      roentgenologist, 


73 


either  by  the  fluoroscopic  screen  or  photo- 
graphic plate,  then  sets  the  instrument  on  the 
skin  overlying  the  foreign  body  and  so  ad- 
justs the  indicator  that  it  not  only  points 
directly  toward  the  foreign  body  but  if 
pushed  into  the  tissues  would  impinge  upon 
it  at  a  depth  marked  on  the  indicator.  He 
then  marks  on  the  skin  the  three  points  on 
which  the  legs  rest  and  tightens  all  the  ad- 
justments, so  that  the  legs  and  indicator  are 
firmly  fixed  in  their  relative  positions.  The 
indicator  is  so  constructed,  however,  that  it 
can  be  swung  the  whole  extent  of  its  sup- 
porting arc  without  losing  its  sight  line.  As 
the  entire  apparatus  can  be  sterilized  it  is 
simply  handed  to  the  surgeon  who  places  its 
legs  on  the  corresponding  skin  marks  and  fol- 
lows the  direction  of  the  pointer  to  the  foreign 
body.  As  the  indicator  can  swing  on  its  arc 
without  losing  its  sight  line  it  can  always  be 
so  placed  as  not  to  interfere  with  the  surgeon. 
Fluoroscopy  has  also  been  developed  to  a 
point  where  its  actual  use  in  the  operating 
room  at  the  time  of  operation  is  perfectly 
feasible.  Not  only  that,  but  the  principle  of 
stereoscopy  successfully  used  for  some  time 
in  roentgenology  has  been  so  applied  that 
stereoscopic  fluoroscopy  is  now  possible. 
While  the  apparatus  has  had  little  more  than 
a  laboratory  test,  this  was  so  successful  that 
the  invention  promises  soon  to  become  of 
great  value  when  it  is  desirable  to  operate 
under  fluoroscopic  control. 


74 


Regional  Surgery. 

When  it  comes  to  a  survey  of  lessons 
learned  that  pertain  to  regional  surgery  it  is 
found  that  outside  the  special  application  of 
general  methods  of  wound  treatment  already 
described  to  meet  regional  requirements,  little 
that  is  new  has  been  gained.  Be  that  as  it 
may,  however,  the  new  conceptions  of  wound 
treatment  are  readily  adaptable  to  all  regions 
of  the  body  and  when  utilized  prove  most 
efficient.  Specialization  in  regional  surgery 
had  before  the  war  been  a  recognized  ten- 
dency that  enabled  certain  men  to  become 
especially  expert  in  limited  fields.  As  the 
war  progressed  this  tendency  was  fostered  by 
the  provision  that  every  effort  be  made  to 
segregate  head  wounds,  for  example,  in 
special  hospitals  where  they  came  under  the 
care  of  surgeons  specially  fitted  and  trained 
to  deal  with  them.  Not  only  did  patients 
thereby  receive  better  treatment,  but  mor- 
tality tables  were  improved  and  opportunity 
presented  for  intensive  study.  At  this  point 
let  it  be  emphasized  once  for  all  that  what 
developments  in  regional  surgery  have  ap- 
peared are  confined  strictly  to  traumatic 
lesions  and  that  it  by  no  means  follows  that 
the  lessons  learned  apply  equally  well  to  the 
pathological  conditions  more  frequently  en- 
countered in  civil  life. 

Head. 

The  danger  from  early  evacuation  of  op- 
erated head  cases  is  perhaps  greater  than  in 


75 


any  other  class  of  patients.  It  has  been  con- 
clusively proved  that  delayed  head  operation 
is  far  preferable  to  prompt  operation  followed 
by  immediate  evacuation.  Furthermore, 
undue  haste  in  subjecting  the  patient  to 
operation  often  proves  to  be  a  fatal  error  in 
judgment.  For  at  least  twenty-four  hours 
after  injury  the  brain  is  liable  to  be  edematous 
and  to  extrude  unduly  if  operated  on  in  this 
interval ;  whereas  delay  allows  not  only  ab- 
sorption of  the  edema  but  also  the  formation 
of.  adhesions  between  dura  and  pia  which 
lessen  the  liability  of  spreading  infection  over 
the  brain  surface.  A  slow  pulse  is  a  wel- 
comed sign  that  recovery  may  follow  and  is 
not  to  be  construed  that  operation  is  urgently 
needed,  but  rather  is  worth  doing.  Nor  is  it 
necessarily  a  sign  of  injurious  compression  de- 
manding prompt  relief ;  for  it  occurs  with  any 
wide  exposure  of  the  brain.  And  especially 
significant  is  the  observation  that  a  slow 
pulse,  irrespective  of  the  type  of  wound, 
means  that  the  patient  travels  well.  More- 
over, immediate  operation  in  many  head  cases 
is  followed  by  an  alarming  drop  in  blood  pres- 
sure. Yet  the  ever  present  danger  of  infec- 
tion has  to  be  reckoned  with  and  the  necessity 
for  early  operation  on  that  score  balanced 
against  the  advantages  of  delay.  The  im- 
mediate problem  is  mechanical  and  microbic 
and  must  be  countered  by  mechanical  and 
anti-microbic  measures ;  the  late  problem  is 
functional,  frequently  manifested  only  after  a 


76 


lapse  of  time,  and  must  be  met  by  measures 
sometimes  in  direct  opposition  to  those  im- 
mediately indicated.  Only  the  nicest  judg- 
ment charts  the  safest  middle  course. 

Some  interesting  and  valuable  data  have 
been  obtained  from  many  repeated  blood  pres- 
sure determinations  that  have  considerable 
diagnostic  and  prognostic  significance.  A 
compound  fracture  of  the  skull  with  the  dura 
intact  causes  a  high  systolic  reading;  \vherea3 
a  penetrated  dura,  provided  there  is  free  drain- 
age, gives  a  low  systolic  pressure.  Any 
wound  involving  the  ventricles  is  accom- 
panied by  a  high  systolic  level.  By  converse 
reasoning,  therefore,  blood  pressure  deter- 
minations offer  a  clue  as  to  the  nature  and 
severity  of  cranial  injury.  Whatever  the  early 
behavior  of  the  blood  pressure  it  tends  to  be- 
come unstable,  and  when  in  that  state  consti- 
tutes a  dangerous  period  for  operation. 

Depression  of  skull  fragments  is  not  the 
usual  cause  of  symptoms  and  their  immediate 
removal  is  not  therefore  to  be  undertaken 
rashly.  Symptoms,  paralytic  and  otherwise, 
are  due  not  to  depressed  fractures  but  to  de- 
struction or  commotion  of  brain  matter  not 
remediable  by  operation.  As  a  general  rule 
depressed  fractures  over  the  longitudinal  sinus 
should  in  the  first  instance  be  left  alone.  A 
symptom  syndrome  comprising  immediate 
spastic  paralysis  of  the  legs  frequently  as- 
sociated with  static  paresis  of  the  proximal 
segments  of  the  arms,  means  occlusion  of  the 


77 


superior  longitudinal  sinus  and  of  the  veins 
that  enter  it  by  a  depressed  fracture  of  the 
vertex  of  the  skull.  Surgical  intervention  in 
such  cases  gave  very  unsatisfactory  results, 
whereas  rest  alone  effected  many  cures. 

Osteoplastic  flaps  of  scalp  and  bone  prob- 
ably constitute  the  best  operative  technique. 
The  dura,  if  uninjured  or  inexpressive  of  un- 
derlying injury,  should  not  be  opened.  At- 
tempts to  reach  missiles  or  fragments  deeply 
imbedded  in  the  brain  are  not  justifiable  when 
the  procedure  results  in  further  injury,  for 
they  cause  little  subsequent  trouble  unless 
heavy  enough  to  compress  the  brain  when  the 
patient  moves.  Guilty  weight  is  present  when 
the  fragment  is  seen  to  travel  by  gravity 
through  brain  tissue,  a  course  of  events 
readily  disclosed  by  repeated  X  ray  plates. 
Advantage  may  be  taken  of  this  tendency  to 
travel.  By  placing  the  wound  area  most  de- 
pendent fragments  may  later  be  shaken  out 
along  the  original  wound  track.  On  the  other 
hand  the  brain  resents  sooner  or  later  the 
presence  of  any  abnormality  in  its  immediate 
coverings  or  in  its  substance.  While  some 
small  lesions  or  foreign  bodies  in  the  brain 
have  apparently  caused  no  trouble,  others 
equally  unobtrusive  have  years  later  in- 
augurated intolerable  inconvenience  due  to 
late  effects  on  the  brain.  Because  it  is  impos- 
sible to  foretell  their  final  effect  every  reason- 
able effort  to  remove  foreign  bodies  and  elim- 
inate   abnormalities     should    be    prosecuted. 


78 


Above  all,  whenever  operation  is  attempted  it 
must  never  be  stopped  short  of  completion ; 
palliative  or  incomplete  operation  is, useless; 
let  it  be  all  or  nothing-.  After  all  is  said  and 
done  it  is  the  strict  application  of  the  general 
principles  of  wound  treatment,  early  opera- 
tion, debridement  even  of  pulped  brain,  and 
closure,  that  is  in  cranial  injuries  most  re- 
sponsible for  the  elimination  of  the  destruc- 
tive ravages  of  sepsis.  Without  these  agencies 
even  the  most  skilled  brain  surgeon  would  be 
unable  to  cope  successfully  with  the  infection 
of  delicate  brain  tissue  that  so  often  proves 
rapidly  lethal  or  not  infrequently  permanently 
disabling.  In  every  instance  the  brain  should 
be  covered  and  drainage  if  indicated  limited  to 
the  scalp  only. 

Much  of  the  operative  difficulty  encoun- 
tered in  head  work  has  been  due  to  general 
anesthesia.  Especially  is  this  true  in  intra- 
cranial operations  where  intense  vascular  con- 
gestion invariably  permits  profuse  venous 
bleeding  that  hampers  and  prolongs  necessary 
procedures.  While  in  isolated  instances  in- 
tracranial operations  had  been  performed 
under  local  anesthesia  as  a  necessity,  experi- 
ence of  head  teams  during  the  war  has  made 
local  anesthesia  the  anesthetic  of  choice.  It 
has  so  few  objections  and  so  many  advantages 
that  it  promises  to  become  universal.  Con- 
trary to  expectation  the  dura  has  been  found 
to  be  insensitive  to  a  marked  degree  except 
when  twisted  or  stretched,  and  except  at  the 


79 


base  of  the  skull  where  it  is  closely  adherent 
to  bone.  The  brain  itself  has  long  been 
known  to  be  insensitive.  A  preliminary  dose 
of  a  third  of  a  grain  of  morphine  thirt}^  min- 
utes before  operation  is  routine  except  in  the 
presence  of  marked  intracranial  pressure. 
The  best  anesthetic  is  a  solution  of  procaine 
0.5%  to  every  ounce  of  which  is  added  15 
minims  of  adrenalin,  i  :ioooo.  As  much  as 
six  ounces  of  this  solution  have  been  used 
without  causing  toxic  effects.  Massive  infil- 
tration of  tissues  to  be  incised  and  a  wait  of 
at  least  fifteen  minutes  between  injection  and 
operation  are  indispensable  factors  for  success. 
Extensive  osteoplastic  flaps  and  all  decom- 
pression operations  can  be  performed  pain- 
lessly. The  adrenalin  proves  such  an  efficient 
hemostatic  that  troublesome  oozing  is  con- 
spicuously absent,  which  not  only  adds  to  the 
surgeon's  comfort  but  greatly  shortens  the 
length  of  the  operation.  Already  current 
medical  literature  records  instances  of  enthu- 
siastic approval  of  local  anesthesia  for  cranial 
operations,  showing  that  the  procedure  is 
being  eagerly  welcomed  and  quickly  adopted. 

Spine. 
The  lack  of  experience  and  the  absence  of 
knowledge  of  the  pathology  of  gun  shot 
w^ounds  of  the  spine  led  to  a  stagnation  of 
effort  in  this  region.  In  civil  life  there  had 
been  always  a  reluctance  to  tackle  by  surgical 
interference  injuries  of  the  spinal  cord.     This 


80 


reluctance  is  directly  traceable  to  the  observa- 
tion that  many  times  cases  improve  without 
operation  in  spite  of  abnormal  conditions  sur- 
rounding the  cord;  that  in  most  instances 
cases  operated  either  die  or  recover  much  as 
would  have  been  their  fate  without  operation ; 
and  finally  that  the  technical  difiiculties  of 
classical  laminectomy,  the  loss  of  blood  it  en- 
tails and  the  doubtful  results  it  affords,  make 
operative  measures  too  risky.  War  experi- 
ence has  done  little  to  mitigate  the  objections. 

Paraplegia,  partial  or  complete,  remains  the 
diagnostic  sign  of  cord  injury.  Three  distinct 
types  of  paraplegia,  however,  are  to  be  recog- 
nized :  one  in  which  the  symptoms  are  due 
to  local  concussion ;  another  in  which  the  cord 
is  organically  severed ;  and  a  third  in  which 
paraplegia  develops  only  after  a  lapse  of  time. 

The  paralyzing  effects  of  local  concussion 
are  often  marked,  but  usually  begin  to  clear 
up  within  a  few  days.  Slight  local  injuries, 
however,  even  when  indirectly  inflicted,  are 
frequently  associated  with  extensive  edema, 
hemorrhage,  softenings,  and  not  infrequently 
with  ascending  cavity  formation  which  may 
extend  a  considerable  distance  both  above  and 
below  the  level  of  the  original  injury.  Such 
changes  can  obviously  not  be  relieved  by  any 
reasonable  operation ;  and  the  fact  that,  apart 
from  secondary  cavities  that  develop  later, 
they  occur  immediately  or  within  a  very  short 
time  of  the  infliction  of  the  injury,  diminishes 
the  favorable  prospect  of  any  surgical  inter- 


81 

ference.  When  the  track  of  the  missile  and 
X-ray  plates  rule  out  vertebral  injury  that 
might  compress  the  cord  the  immediate  onset 
of  paraplegia  is  due  solely  to  concussion.  If, 
however,  the  symptoms  fail  to  clear  up  as 
expected,  the  probabilities  are  that  the  later 
formation  of  blood  clot  has  by  compression  of 
the  cord  perpetuated  the  paraplegia  primarily 
due  to  the  concussion  whose  effects  have  dis- 
appeared. In  this  comparatively  small  group 
of  cases  partial  laminectomy  for  the  removal 
of  the  clot  is  absolutely  indicated.  Not  only 
is  the  operation  the  sole  chance  for  permanent 
relief,  but  its  results  are  brilliantly  successful 
and  marred  by  an  insignificant  mortality. 

When  the  path  of  the  missile  demonstrates 
that  paraplegia  is  due  to  organic  division  of 
the  cord  the  case  is  hopeless.  All  operative 
interference  is  absolutely  contra-indicated. 
Unfortunately  complete  transverse  destruc- 
tion of  the  cord  is  often  very  difficult  of  im- 
mediate determination.  Even  relatively  slight 
injuries  of  the  cord  often  produce  for  the  first 
few  days, — the  very  period  when  operation 
offers  the  best  chance  of  success, — symptoms 
that  may  be  confused  with  those  of  total  and 
irreparable  damage  which  contra-indicates 
operation.  In  such  a  dilemma  there  is  some 
comfort  to  be  derived  from  the  observation 
that  while  the  symptoms  undoubtedly  are  in 
many  instances  largely  or  in  part  due  to  reme- 
diable compression  of  the  cord  by  either  a 
missile   or    fragment   of   depressed    bone,   the 


immediate  iutra-spinal  lesions  due  to  concus- 
sion already  exist  and  are  irremediable  by- 
operation.  Some  clinical  indication,  there- 
fore, of  the  severity  of  spinal  injury  is  urgent- 
ly necessary  before  operation  can  be  reason- 
ably undertaken.  The  safest  guide  is  afford- 
ed by  the  form  and  character  of  the  sensory 
disturbances,  and  especially  by  the  changes 
and  modifications  in  the  reflexes  of  the  affect- 
ed limbs. 

The  type  of  paraplegia  that  develops  only 
after  a  varying  lapse  of  time  is  as  a  general 
rule  the  most  favorable  for  operation.  The 
paraplegia  is  due  to  compression  either  from 
the  tardy  formation  of  blood  clot  or  from  the 
displacement  of  a  bone  fragment  caused  dur- 
ing movement,  or  perhaps  to  both.  In  any 
event  compression  has  been  of  short  dura- 
tion and  permanent  injury  to  the  cord  is 
therefore  unlikely.  If  operation  is  performed 
immediately  the  results  are  uniformly  bril- 
liant. 

Wider  knowledge,  therefore,  has  not  greatly 
extended  the  scope  of  operative  interference. 
The  tendency  is  toward  partial  rather  than 
classical  laminectomy,  and  as  in  cranial  work 
to  favor  local  instead  of  general  anesthesia. 
Increased  confidence  has  been  gained  in  the 
utility  of  placing  muscle  graft  over  an  open- 
ing in  the  spinal  membranes  when  leakage  of 
cerebro-spinal  fluid  has  complicated  the 
operation ;  for  an  intact  spinal  dura  has  be- 
come of  notable  prognostic  omen. 


83 

Chest. 

Wounds  of  the  chest  had  been  seen  a  long^ 
time  before  surgeons  recognized  that  such 
cases  must  be  treated  on  principles  which 
govern  in  other  parts  of  the  body.  When  so 
treated,  with  such  modifications  as  the  exigen- 
cies of  the  region  demand,  chest  wounds 
need  no  longer  show  the  frightful  mortality 
formerly  obtained.  Success  will  not  follow, 
however,  unless  it  is  appreciated  that  it  is 
unnecessary  actually  to  pierce  the  chest  wall 
in  order  to  caus^  intra-thoracic  injury ;  for 
tangential  wounds  of  the  parieties  only  may 
be  accompanied  by  intra-pleural  damage  al- 
most as  severe  as  though  the  missile  had 
penetrated  the  chest  wall  or  even  traversed 
the  lung.  Worthy  of  equal  consideration  is 
the  discovery  that  injury  to  the  other  lung 
by  contra-coup  is  not  at  all  uncommon,  and 
is  evidenced  by  subpleural  and  intra-pul- 
monary  hemorrhages,  large  and  small,  that 
readily  succumb  to  broncho-pneumonia.  x\s 
in  all  wounds  the  immediate  danger  is  from 
hemorrhage  and  shock;  sepsis  is  the  late  peril. 
The  immediate  dangers,  owing  to  the  anatomy 
and  physiology  of  the  region,  may  be  compli- 
cated and  aggravated  by  the  sudden  or  gradual 
formation  of  a  pneumothorax. 

The  consequences  of  pneumothorax  are  by 
no  means  limited  by  the  effects  of  collapse  of 
that  lung.  Air  in  one  pleural  cavity,  under 
ordinary     atmospheric    pressure,     compresses 


84 

the  opposite  lung  and  displaces  mediastinal 
structures  toward  the  uninjured  side.  Sud- 
denly created  pneumothorax  precipitates  these 
changes  so  quickly  that  natural  compensatory 
measures  are  for  the  moment  inhibited.  Res- 
piration is  immediately  and  seriously  em- 
barrassed. Rapid  and  labored  respiratory  ef- 
forts throw  the  mediastinal  structures  into 
unfamiliar  oscillations  or  flutter  that  rapidly 
induces  a  state  of  pleural  shock.  Acting 
cither  alone  or  in  conjunction  with  ordinary 
shock  pleural  shock  is  very  quickly  fatal. 

Pneumothorax  becomes,  then,  the  immedi- 
ately pressing  factor  to  be  considered  in  all 
chest  wounds.  The  small  penetrating  Avounds 
of  rifle  bullets  are  so  promptly  plugged  by  the 
instant  collapse  of  surrounding  soft  tissues 
that  pneumothorax  is  entirely  prevented. 
Somewhat  larger  wounds,  after  slowly  allow- 
ing partial  pneumothorax  to  form,  become  ef- 
fectually stopped  with  blood  clot  before  the 
condition  is  complete,  and  its  evil  intents  are 
thereby  checked.  Such  wounds  are  almost 
never  followed  by  any  of  the  distressing  symp- 
toms incident  to  pneumothorax,  and  left  alone 
do  perfectly  well  when  uncomplicated  by 
hemorrhage  or  sepsis.  It  is  always  the  large, 
gaping  openings  permitting  immediate,  com- 
plete, and  persistent  ingress  of  air,  the  so- 
called  sucking  wounds,  that  quickly  induce  all 
the  attendent  evils  of  pneumothorax.  And 
yet  if  nature's  efiforts  be  promptly  imitated 
and  soft  tissue,  even  skin  alone,  be  so  sutured 


85 

as  to  seal  the  pleural  opening,  much  of  the  im- 
minent danger  is  effectually  eliminated. 
Wounds  so  lacerated  as  to  prohibit  closure  by 
suture  can  be  very  satisfactorily  sealed  with 
an  impervious  dressing  bound  tightly  to  the 
chest.  Needless  to  say  prompt  checking  of 
the  to  and  fro  current  of  air  lessens  the  in- 
spiration through  the  wound  of  infected  ma- 
terial that  leads  to  subsequent  pleural  sepsis. 
Fortified  by  rest,  and  the  administration  of 
sedatives  when  indicated,  cases  so  treated  re- 
vive in  a  most  astounding  manner  that  enables 
them  to  cope  successfully  with  later  complica- 
ions  equally  serious.  Strange  as  it  may  seem, 
later  operative  pneumothorax  is  curiously  less 
dangerous  than  formerly  thought.  Compli- 
cated pressure  cabinets,  both  negative  and 
positive,  as  well  as  intratracheal  insufflation, 
all  of  which  were  devised  to  preserve  lung  ex- 
pansion and  prevent  pneumothorax,  have  to  a 
large  exent  been  discarded  as  unnecessary. 
As  a  matter  of  fact  an  expanded  lung  consti- 
tutes a  distinct  difflculty  in  thoracic  surgery, 
for  only  a  collapsed  lung  can  be  palpated  and 
manipulated  at  all  nicely.  Furthermore, 
pneumothorax  is  far  from  being  an  unmixed 
evil.  The  collapse  of  the  lung  that  invariably 
ensues  arrests  by  compression  an  otherwise 
often  fatal  pulmonary  hemorrhage.  With  to 
and  fro  tide  of  air  checked,  the  presence  of 
pleural  air  becomes  so  beneficial  in  arresting 
bleeding  that  its  loss  by  absorption  must  often 
be  replaced  artificially  lest  expansion  of  lung 


86 


Stretch  or  displace  the  clot  that  occludes  a 
torn  pulmonary  vessel.  In  fact,  a  deliberately 
produced  artificial  pneumothorax  by  injecting 
air  through  an  aspirating  needle  may  easily 
prove  to  be  the  forlorn-hope  measure  that  ar- 
rests hemorrhage  in  a  patient  too  exsanguin- 
ated to  withstand  a  more  radical  procedure. 

Chest  injuries  that  do  not  succumb  to  shock, 
yet  prove  fatal  within  the  first  few  hours,  die 
of  hemorrhage.  Very  often  the  two  are  so 
closely  and  interdependently  related  that  they 
cannot  be  differentiated  and  death  is  due  to 
shock-hemorrhage.  As  operation  cures  the 
latter  but  kills  the  former,  decision  is  often 
agonizing.  Be  that  as  it  may  the  proper  at- 
titude is  to  expect  hemothorax  in  every  chest 
wound  and  be  prepared  to  deal  with  it.  Blood 
in  the  pleural  cavity  is,  like  air,  not  entirely  of 
evil  import.  It  gradually  arrests  bleeding  by 
compressing  the  lung  that  is  lacerated,  which 
is  most  desirable  provided  hemostasis  occurs 
before  the  patient  becomes  exsanguinated. 
Once  checked,  the  bleeding  does  not  recur. 
Patients  die  more  often  from  external  hemor- 
rhage in  the  wound  than  from  intra-pleural. 
Hemoptysis  in  chest  wounds  is  seldom  fatal 
and  secondary  hemoptysis  from  that  cause  is 
very  rare.  Hemothorax,  then,  is  not  to  be 
dealt  with  rashly.  As  a  rule  the  profound 
shock  that  accompanies  it  serves  sufficiently 
to  contra-indicate  radical  operative  measures. 
An  attitude  rather  of  keen  watchfulness  is  to 
be  taken.    The  level  of  the  nipple  is  arbitrarily 


87 

assumed  to  be  the  upper  limit  of  a  hemothorax 
that  does  not  threaten  life  by  exsanguination. 
While  hemothorax  certainly  checks  pulmon- 
ary hemorrhage  by  compressing  the  injured 
lung,  it  may  also  compress  the  heart  and  op- 
posite lung  and  by  its  massiveness  prove  fatal 
by  asphyxiation.  Mechanical  interference 
with  respiration,  therefore,  constitutes  the 
only  immediate  indication  for  intervention 
vi^hich  is  best  limited  to  aspiration  of  only 
enough  blood  to  relieve  the  distress.  If  more 
is  removed  there  is  danger  of  secondary 
hemorrhage  from  lung  expansion  that  tears 
aw^ay  the  clot  from  a  torn  vessel.  If  me- 
chanical distress  returns  it  is  best  not  to 
repeat  aspiration  but  to  operate  radically  and 
check  the  hemorrhage.  At  the  end  of  a  week, 
however,  if  all  goes  well,  danger  of  such  sec- 
ondary hemorrhage  is  eliminated,  and  it  is 
best  to  aspirate  freely  in  order  to  avoid  the 
formation  of  adhesions  which  by  preventing 
lung  expansion  court  the  onset  of  broncho- 
pneumonia. Because  of  the  sinister  possibili- 
ties of  adhesions  it  is  permissible  to  aspirate 
the  blood  at  any  time  and  immediately  replace 
it  with  air  which  just  as  effectually  arrests 
bleeding  and  is  not  so  liable  to  promote  the 
formation  of  distorting  adhesions.  Further- 
more, a  hemothorax  is  very  liable  to  infection 
which-  when  it  occurs  runs  the  distressing 
course  of  an  empyema.  On  the  other  hand, 
pneumothorax  is  more  often  accompanied  by 
pulmonary    infections,    while    a    hemothorax 


88 

bears  the  brunt  of  infection  and  spares  the 
compressed  lung.  It  is  only  natural,  there- 
fore, that  perfectly  tenable  differences  of 
opinion  exist  as  to  the  relative  value  and  inoc- 
cuousness  of  air  and  blood  in  the  pleural 
cavity.  Both  accomplish  the  same  purpose  in 
the  same  way :  each  has  its  merits  and  faults 
that  are  to  be  nicely  balanced  in  indi\'idual  in- 
stances before  a  decision  is  made. 

There  are  of  course  cases  in  which  the 
laceration  of  intra-pleural  structures  is  so  ex- 
tensive, and  the  resultant  hemorrhage  so  pro- 
fuse, that  they  are  obviously  hopeless.  Such 
patients  die  within  a  very  few  minutes.  Be- 
tween these  cases  and  those  whose  hemo- 
thorax for  the  moment  at  least  is  to  be  treated 
conservatively,  there  exists  a  large  number  of 
border-line  cases  requiring  the  keenest  judg- 
ment. Immediate  radical  operation  will  save  a 
surprising  number  of  these.  The  wise  sur- 
geon stands  ready  to  interfere  the  moment  he 
is  convinced  from  the  patients  behavior  that 
conservative  methods  are  failing  to  check  the 
hemorrhage.  Local  anesthesia  is  the  method 
of  choice.  The  chest  is  to  be  opened  widely 
by  subperiosteal  resection  of  the  fourth  rib 
from  the  junction  of  bone  and  cartilage  pos- 
teriorly for  six  or  seven  inches,  followed  by 
incision  of  the  pleura  through  the  periosteal 
bed.  This  approach  gives  the  best  e^fposure 
and  should  be  chosen  irrespective  of  the  loca- 
tion of  the  injury  unless  the  latter  ofters  ap- 
proximately   as    favorable   a    site.     Strip    the 


89 

periosteum  and  pleura  carefully  from  the  pos- 
terior surfaces  of  the  adjacent  ribs  above  and 
below,  when  it  will  be  easily  feasible  by  suit- 
able   retractors    to    spread    the    wound    suf- 
ficiently wide  to  permit  free  entrance  of  the 
surgeon's  hand.     Through  this  wound  the  col- 
lapsed lung  can  be  easily  delivered  and  freely 
palpated.     Pulse  and  respiration  are  not  at  all 
seriously  aft'ected  if  the  lung  is  handled  gently. 
Wounds  of  the  diaphragm  are  first  attended 
to,  and  through  the  rent  any  abdominal  meas- 
ure that  is  indicated  should  be  quickly  per- 
formed, enlarging  the  diaphragmatic  wound  if 
necessary.      Shell    fragments,    bone    splinters, 
and  bits  of  other  foreign  material  are  a  serious 
menace   and   must   be   removed   even   though 
fresh  incision  into  the  lung  be  necessary.    All 
wounds  in  pulmonary  tissue  must  be  treated 
by  thorough  debridement  and  firmly  sutured, 
not  only  to  control  hemorrhage,  but  also  to 
remove  contamination  and   protect  the   adja- 
cent pleura  which  is  less  resistant  to  infection. 
It  is  surprising  how  well  the  elastic  lung  lends 
itself  to  suture  without  tearing.     Mediastinal 
missiles    are    to    be    left    alone.     Attempts    at 
their  removal  are  surely  followed  by  disaster, 
for   n\ediastinal   structures   are   strangely   ad- 
verse  to   manipulation.     After  gently  wiping 
the   pleural   cavity  clean  of   free   and   clotted 
blood  suture  the  wound  in  the  pleura,  very  ac- 
curately everting  the  edges  in  order  to  bring 
serous   surfaces  smoothly  together.     It   is   at 
this  stage  that  the  value  of  placing  the  inci- 


90 

sion  in  the  periosteal  bed  is  appreciated,  for 
the  fibrous  periosteum  prevents  the  sutures 
from  tearing  through  the  delicate  pleura. 
Drainage  should  never  be  carried  into  the 
pleural  cavity  but  only  down  to  the  sutured 
serous  membrane.  The  last  step  is  the  as- 
piration of  intra-pleural  air  in  order  to  stimu- 
late lung  expansion  and  prevent  distorting  ad- 
hesions. After  operation  patients  are  kept  in 
a  semi-upright  position,  given  morphine 
judiciously,  and  never  transported  under 
eight  days. 

However  managed,  all  chest  injuries  are 
sooner  or  later  liable  to  infection.  The  lesions 
vary  from  broncho-pneumonia,  abscess,  and 
gangrene  of  the  lung  to  massive  empyemata. 
Anaerobic  infection  of  hemothorax  is  common, 
about  10%,  and  is  most  frequently  due  to  the 
bacillus  Welchii  and  bacillus  sporogenes. 
Jaundice,  especially  if  associated  with  epis- 
taxis,  is  an  index  of  a  very  severe  type  of  in- 
fection with  anaerobes.  The  war  has  added 
little  that  is  new  to  operative  measures  for 
dealing  with  all  such  late  complications,  but 
post-operative  care  has  been,  especially  for 
empyema,  completely  revolutionized.  The  im- 
mediate application  of  Carrel-Dakin  technique 
to  this  attection  has  made  the  care  of  such 
cases  a  pleasure  to  all  concerned.  Through 
the  operative  drainage  wound  Carrel  tubes  are 
inserted  towards  the  apex  of  the  lung,  into  the 
axilla,  across  the  diaphragm,  and  down  into 
the    posterior    costo-phrenic    space.      Regular 


91 


instillations  of  Dakin's  solution  quickly  checks 
purulent  discharge,  obliterates  all  odor,  and 
promptly  institutes  a  marvelous  improvement 
in  the  patients'  general  condition.  Occasion- 
ally a  broncho-pleural  communication  sucks 
Dakin's  solution  into  the  throat  with  most 
distressing  symptoms,  but  generally  a  change 
in  posture  or  more  gentle  instillation  over- 
comes the  difficulty.  In  time  bacterial  count 
of  the  secretion  demonstrates  sterilization  of 
the  cavity.  The  tubes  are  then  withdrawn 
and  the  wound  sealed  with  an  impervious 
dressing  when  healing  usually  takes  place. 
X  ray  plates  of  the  failures,  after  the  sinus  has 
been  infected  with  barium,  show  either 
necrosis  of  rib,  a  pleural  pocket  with  a  small 
track  leading  to  the  main  sinus,  or,  which  is 
not  at  all  uncommon  and  very  important,  an 
isolated  collection  of  pus  totally  independent 
of  the  main  lesion.  Under  appropriate  treat- 
ment all  but  a  very  few  such  cases  can  be  com- 
pletely healed. 

Empyema. 
It  is  only  biased  enthusiasts  who  still  main- 
tain that  empyemata  are  always  cured  quicker 
and  surer  by  Carrel-Dakin  treatment  than  by 
any  other  method.  First  reports  of  cases  so 
treated,  it  is  true,  showed  marvelously  quick 
sterilization  of  cavities  amply  proved  by  bac- 
terial count  and  culture  control.  The  wounds 
were,  therefore,  closed  by  secondary  suture 
and  the  patients  discharged  as  cured,  only  to 


92 

develop  weeks  later  symptoms  which  on  in- 
vestigation denoted  persistent  pleural  sepsis 
that  only  further  operative  treatment  eradi- 
cated. When  it  is  remembered  that  the  Car- 
rel-Dakin  technique  as  applied  to  empyemata 
transgresses  all  the  surgical  principles  that  are 
vehemently  stressed  as  essential  fore-runners 
of  its  success,  it  is  not  so  surprising  that  the 
method  sometimes  fails  completely,  and  not 
infrequently  proves  to  be  no  quicker  nor  surer 
than  other  methods.  An  empyema  is  essen- 
tially a  bottle  shaped  cavity  half  of  whose 
walls  are  rigid  and  the  other  half  equally  im- 
possible of  collapse.  Carrel-Dakin  technique 
cannot  accomplish  its  marvelous  results  in 
such  a  cavity  wherever  situated,  and  should 
not  be  expected  to.  It  is  solely  because  of 
these  ineradicable  limitations  that  Carrel- 
Dakin  treatment  has  been  somewhat  disap- 
pointing in  empyema.  What  it  does  accom- 
plish, however,  in  these  cases  that  is  distinctly 
worth  while,  is  promptly  and  markedly  to 
lessen  the  discharge ;  is  to  keep  the  patient 
smelling  sweet  and  clean ;  is  to  make  the  dress- 
ings easy ;  and  is  to  improve  the  patients'  gen- 
eral condition  more  quickly  and  more  noticeably 
than  does  any  other  method  of  treatment. 

The  influenza  epidemic  with  its  high  in- 
cidence of  complicating  empyema  aroused  ex- 
orbitant hopes  that  at  last  through  sheer  ex- 
perience with  vast  numbers  definite  conclu- 
sions regarding  the  proper  management  of 
pyothorax    would    be    established.     Not    only 


93 

were  expectations  dashed,  but  only  recently 
has  any  order  begun  to  emerge  from  the  chaos 
into  which  the  whole  subject  was  thrown  by 
the  combative  adherents  of  early  and  late  op- 
eration. As  the  two  camps  were  about 
equally  divided,  published  equally  favorable 
statistics,  and  later  admitted  respective  statis- 
tical fallacies  that  exactly  offset  each  other 
and  preserved  relative  equilibrium,  confusion 
was  further  confounded.  Gradually  a  sem- 
blance of  order  is  being  restored  by  mutual 
concessions  compelled  by  irrefutable  facts.  In 
influenza  pleural  effusion  develops  early  and 
massively.  At  first  the  effusion  is  serous  and 
becomes  purulent  only  after  it  has  persisted 
for  a  week  or  ten  days.  Cases  that  are  fatal 
in  the  period  of  developing  p'leural  effusion 
die,  not  from  the  eft'usion,  but  from  the  con- 
current pulmonary  process,  except  when  by 
its  massiveness  the  former  mechanically  em- 
barrasses cardiac  and  respiratory  action.  Con- 
servative management  of  influenzal  pleural  ef- 
fusion compels  an  attitude  of  non-interference 
until  signs  of  cardiac  or  respiratory  difficulty 
supervene,  when  intervention  is  to  be  limited 
to  the  aspiration  of  sufficient  fluid  to  afford 
relief.  With  a  return  of  embarrassment  as- 
piration can  be  safely  repeated  as  often  as 
necessary  and  a  fair  percentage  of  cases  will 
by  this  means  alone  escape  a  frank  empyema 
and  recover.  Not  until  the  fluid  is  purulent 
should  operation  be  undertaken.  As  a  rule, 
by  the  time  the  effusion  has  become  purulent, 


94 


the  pulmonary  process  has  so  far  subsided 
that  operation  does  not  entail  further  risk  on 
that  score.  Unfortunately,  opinion  is  about 
equally  divided  between  the  merits  of  closed 
or  open  operation  with  or  without  Carrel- 
Dakin  treatment,  and  mortality  and  morbidity 
statistics  fail  definitely  to  settle  the  dispute. 
The  probabilities  are  that  both  methods  are 
equally  good  and  that  the  choice  of  method 
resolves  itself  into  individual  preference  and 
ease  of  after  care. 

Abdomen. 

An  expectant  attitude  in  regard  to  ab- 
dominal wounds  held  longer  than  it  should 
have  solely  because  of  inadequate  provisions 
for  early  operation.  Experience  gained  in  the 
war  fully  confirmed  the  opinion  long  held  that 
abdominal  trauma,  whether  penetrating  or 
not,  demands  in  the  presence  of  any  sign  of 
internal  injury  immediate  exploration.  Clean- 
cut,  small,  penetrating  wounds  made  by  high 
velocity  bullets  are  no  exception ;  for  such 
missiles  however  innocuous  in  other  regions 
raise  havoc  with  hollow  abdominal  viscera. 
The  necessary  operative  technique  for  dealing 
with  traumatic  lesions  of  the  abdomen  was 
with  very  slight  adaptations  copied  directly 
from  that  already  practiced  in  civil  life,  and 
experience  of  general  surgeons  in  the  war  has 
added  little  of  importance  in  the  way  of  tech- 
nique. There  is  noted  a  tendency  to  use 
fewer  suture  lines   in  gastro-intestinal   work ; 


95 

but  this  was  doubtless  practiced  for  the  sake 
solely  of  speed  in  operating  and  will  probably 
not  prevail.  Nevertheless,  the  experience 
demonstrated  the  security  of  even  one  suture 
line  when  time  was  at  a  premium.  End  to 
end  anastomosis  has  gained  a  preference  over 
lateral  now  that  the  fear  of  leakage  at  the 
mesenteric  angle  has  been  once  for  all  dis- 
pelled. Abdominal  drainage  as  usually  prac- 
ticed proved  even  less  effective  than  sus- 
pected. No  new  ideas  were  ofifered  for  the 
management  of  peritonitis;  and  the  sheet 
anchor  against  infection  in  all  other  regions, 
Carrel-Dakin  technique,  is  strictly  contra-in- 
dicated in  the  abdomen  where  Dakin's  solu- 
tion causes  gross  mesenteric  hemorrhages  and 
dissolution.  Intra-peritoneal  wounds  of  the 
bladder  may  be  safely  sutured  without  supra- 
pubic drainage  of  that  viscus,  but  extra-peri- 
toneal wounds  must  be  drained. 

Abdominal  tenderness  some  distance  from 
the  wound  denotes  probable  intra-peritoneal 
injury.  Protruding  omentum  is  not  in  itself 
particularly  dangerous  but  is  an  infallible  in- 
dication for  operation  because  it  signifies  vis- 
ceral injury.  Wounds  of  the  chest,  back,  and 
buttock,  not  directly  involving  the  abdomen, 
may  cause  retro-peritoneal  hematomata  that 
closely  simulate  symptoms  of  intra-abdominal 
injury.  Passage  of  flatus  after  injury  nega- 
tives lesions  in  the  large  gut,  especially  the 
descending  colon.  Distension  of  wounded 
hollow  viscera  does  not  rule  out  a  wound  of 


96 


exit.  Antero-posterior  wounds  are  attended 
with  a  higher  percentage  of  recovery  than  are 
oblique,  transverse,  or  vertical  wounds;  and 
wounds  of  the  lateral  abdomen  are  less  grave 
than  median.  Abdominal  injuries  compli- 
cated by  wounds  of  the  buttock  always  do 
badly. 

Blood  Vessels. 

As  a  rule,  wounds  of  blood  vessels,  large 
enough  to  permit  of  operative  surgery,  proved 
so  immediately  fatal  that  little  opportunity 
was  presented  for  the  development  of  this 
branch  of  surgery.  And  when  the  patients 
survived  the  initial  hemorrhage,  the  nature 
and  extent  of  the  wound  held  the  severed  ends 
of  the  vessel  too  far  apart  to  admit  of  im- 
mediate repair.  The  use  of  Tufifier's  tubes  in 
such  contingencies  very  often  tided  over  the 
critical  period  when  adequate  collateral  cir- 
culation was  being  established.  The  tubes 
generally  become  occluded  with  blood  clot  in 
from  twenty-four  to  seventy-two  hours  and 
should  be  removed  as  soon  as  pulsation  in  the 
vessel  distal  to  the  wound  has  ceased. 

With  complete  division  of  a  main  arterial 
trunk  and  failure  of  collateral  circulation  the 
definite  line  of  demarcation  seen  in  civil  prac- 
tice marking  the  line  of  gangrene  was  curi- 
ously missing  in  war  wounds.  Site  for  am- 
putation had  to  be  determined,  therefore,  by 
noting  the  place  where  the  limb  was  cold  and 
discolored  and  where  capillary  circulation  was 


97 

active  as  shown  by  the  return  of  blush  after 
the  blanch  of  pressure.  Moreover,  arrest  of 
blood  current  at  a  point  considered  favorable 
for  ligature  in  civil  practice  was  often  fol- 
lowed by  gangrene  when  the  arrest  was  due 
to  gun-shot  injury.  Even  small  perforating 
wounds  without  muscle  or  bone  laceration 
were  unhappily  followed  by  such  sequelae. 
The  popliteal  and  both  tibials  stand  out  as 
arteries  injuries  of  which  are  especially  dan- 
gerous to  the  vitality  of  the  limb. 

Lateral  wounds  of  vessel  walls  lacerate  the 
adventitia  and  media  only  at  the  site  of  the 
lesion,  but  in  the  intima  lacerations  radiate 
for  considerable  distances  up  and  down  the 
vessels.  The  rarest  condition  is  found  in  what 
are  known  as  dry  wounds,  in  which  a  small 
arterial  perforation  is  quickly  plugged  by  a 
clot  held  in  position  by  perivascular  tissue. 
Spontaneous  hemostasis  occurs  and  rapid 
aseptic  healing  usually  follows.  Wounds  that 
are  dry  for  eight  to  ten  hours,  however,  may 
then  bleed  and  give  rise  to  the  first  intimation 
of  vascular  injury, 

A  much  more  common  condition  is  diffuse 
hematoma.  The  peri-vascular  tissues  fail  to 
hold  and  blood  is  extravasated  until  its  ten- 
sion equals  blood  pressure.  Further  bleeding 
is  then  checked  spontaneously  and  a  visible 
tumor  appears  when  the  vessel  is  superficial ; 
a  diffuse  swelling  when  it  is  deep.  The  tumor 
mass  undergoes  either  complete  organization 
and  absorption,  or  its  center,  subjected  to  ar- 


98 

terial  pulsation,  softens  and  disintegrates 
while  its  periphery  hardens  and  forms  the  sac 
of  an  aneurysm.  If  the  adjacent  vein  was  in- 
jured at  the  same  time  the  combined  organiza- 
tion and  disintegration  results  in  an  arterio- 
venous aneurysm.  In  all  hematomata  and 
aneurysms  the  immediate  branches  of  the 
main  artery  are  often  concurrently  involved 
and  prevent  the  establishment  of  a  collateral 
circulation  that  would  otherwise  save  the 
limb. 

Absence  of  pulsation  distal  to  vascular  in- 
jury is  not  a  safe  criterion  of  permanent  oc- 
clusion, for  the  vessel  may  be  only  tempor- 
arily plugged  by  a  clot  due  merely  to  contu- 
sion from  direct  impact  without  laceration. 
The  lesion  is  the  result  essentially  of  an  undue 
stretching,  locally  of  the  intima  only ;  locally 
of  intima  and  media;  or  circularly  of  intima 
and  media  around  the  entire  circumference  of 
the  vessel.  The  first  is  almost  symptomless; 
the  second  is  recognized  by  distant  emboli 
denoting  thrombosis  in  the  injured  vessel ;  and 
the  third  is  detected  by  the  fusiform  dilatation 
with  invariable  and  extensive  thrombosis. 

All  hematomata  should  be  evacuated  and 
the  cavity  cleaned  by  debridement.  The 
management  of  the  wounded  artery  itself 
must  be  adapted  to  circumstances.  Ligation 
is  the  simplest,  quickest,  and  generally  the 
best.  When  done,  the  vein  as  well  must  be 
tied.  In  as  much  as  ligation  of  a  main  artery 
in  the  presence  of  a  hematoma  is  followed  by 


99 

partial  or  complete  necrobiosis  in  one  third  of 
the  cases,  it  is  well  before  ligating  to  test  the 
efficiency  of  collateral  circulation.  Under 
temporary  compression  a  small  incision  as 
distally  as  possible  should  bleed ;  the  distal 
end  of  the  compressed  main  vein  should  fill ; 
and  blood  should  escape  from  the  distal  end 
of  the  wounded  main  artery.  If  these  signs 
fail  collateral  circulation  is  not  dependable 
and  vascular  suture  or  amputation  must  be 
chosen. 

Paralyses,  independent  of  concomitant  nerve 
lesions,  may  follow  arterial  injury  and  are  not 
in  all  instances  by  any  means  creditably  ac- 
counted for  as  types  of  Volkmann's  ischemic 
paralysis.  They  are  rather  of  reflex  origin, 
not  inaptly  named  angiotic  paralyses,  and  un- 
like Volkmann's  often  recover.  They  follow 
arterial  injury  that  does  not  efifect  complete 
blockade  of  the  vessel,  and  are  characterized 
by  a  flaccid  muscular  paralysis  distally,  with 
a  wide  spread  loss  of  cutaneous  sensibility 
that  extends  even  above  the  wound.  The  af- 
fection has  been  successfully  treated  by  exci- 
sion of  the  sympathetic  nerves  that  course  the 
sheath  of  the  injured  artery,  periarterial  sym- 
pathectomy. The  muscles  have  in  50%  of  the 
cases  regained  their  tone  and  power,  not  al- 
ways at  once  but  eventually.  The  operation 
is  followed  by  arterial  contraction  for  the  first 
ten  to  twelve  hours  when  a  reaction  sets  in 
that  results  in  vasodilation  which  is  more  or 
less  permanent.     This  vasomotor  sequence  is 


100 

perhaps  worthy  of  pertinent  consideration  as 
a  possible  explanation  of  tardy  hemorrhage  in 
the  so-called  dry  wounds  of  arteries. 

Peripheral  Nerves. 

Of  all  the  surgical  specialities  none  has  had 
graver  problems  in  diagnosis  and  therapy  than 
those  that  fell  to  the  lot  of  neurological  sur- 
geons. It  is  unhappily  true  that  most  of  the 
moot  points,  vital  as  they  are,  must  wait  still 
longer  before  certain  judgment  can  be  pro- 
nounced. Prognosis  remains  especially  un- 
certain. Why,  for  example,  60%  of  nerve 
lesions  recover  spontaneously  with  postural, 
mechanical,  and  electric  treatment  and  40%, 
though  apparently  no  more  serious,  do  not, 
cannot  yet  be  explained.  Because  a  nerve 
fiber  is  incapable  of  stimulation  does  not  mean 
that  it  is  not  in  a  condition  of  possible  spon- 
taneous regeneration.  Injured  nerves  exhibit 
such  a  surprising  tendency  to  recover  in  time 
that  it  is  always  safe  to  defer  reparative  op- 
eration for  a  month  where  soft  parts  only  are 
involved ;  for  two  to  three  months  where 
bones  are  implicated ;  and  indefinitely  as  long 
as  progress  toward  recovery  is  shown. 

Nerves  withstand  infection  remarkably  well. 
They  should,  therefore,  when  divided,  be 
united  at  the  first  deliberate  operation  irre- 
spective of  the  condition  of  the  wound.  Fif- 
teen inches  of  nerve  may  be  stripped  without 
fatally  destroying  its  capillary  circulation. 
The    severed    ends    should    be    approximated 


101 

with  interrupted  sutures  that  pass  only- 
through  the  sheath  and  that  do  not  twist  the 
nerve.  As  union  of  nerve  structure  is  well 
advanced  in  four  days,  cat-gut  is  the  suture 
material  of  choice.  Always  lay  the  sutured 
nerve  in  healthy  tissue,  preferably  muscle,  as 
far  from  the  site  of  the  later  scar  as  possible. 
Fascia,  fat,  or  other  tissue  tubes  wrapped 
around  the  nerve  are  of  questionable  value 
and  may  be  harmful  by  constricting  the  nerve 
and  inhibiting  new  blood  supply.  Transplan- 
tation of  one  nerve  into  another  is  much  less 
effective  than  tendon  transfer.  From  six  to 
eight  weeks  is  required  for  firm  healing  of  a 
nerve,  during  all  of  which  time  it  must  be 
protected  from  the  slightest  stretching. 

Late  operation  for  nerve  injury  is  indicated, 
for  complete  division  of  a  trunk;  incomplete 
division  w^hen  progress  toward  recovery 
ceases ;  and  for  severe  neuralgic  pain.  The 
last  named  indication  has  received  consider- 
able attention  because  of  its  frequency  and 
because  of  a  better  understanding  of  the 
causes  of  the  pain.  Outside  of  those  cases 
where  nerve  trunks  are  caught  and  pinched  in 
scar  tissue,  pain  in  injured  nerves  and  their 
distribution  is  due  to  neuromata.  A  neuroma 
is  merely  an  over-growth  of  nerve  fibers  out- 
side the  sheath  and  represents  nature's  per- 
verted efforts  of  axis  cylinder  extension. 
Neuromata  are  central,  lateral,  or  terminal, 
depending  on  the  nature  and  site  of  the 
original     wound     of     the     nerve.       Wherever 


192 

found  neuromata  are  to  be  widely  excised,  sec- 
tioning nerve  structure  until  no  further  scar 
tissue  is  found. 

For  complete  division  of  a  nerve  trunk  the 
earliest  prudent  occasion  must  be  chosen  for 
operation.  Delay  until  concommitant  wounds 
of  bone  and  soft  parts  are  long  healed  is  not 
only  justifiable  but  should  be  the  rule.  It  is 
especially  in  regions  deprived  of  innervation 
that  bacteria  survive  latently  for  long  periods 
only  to  jump  into  virulent  activity  when  dis- 
turbed. Throughout  the  interval  of  waiting, 
however,  every  means  of  massage,  electricity, 
and  hydro-therapy  should  be  constantly  in- 
voked to  prevent  contractures  and  to  preserve 
suppleness  of  joints  and  muscles  to  the  end 
that  the  nerve  may  later  have  healthy  tissues 
to  innervate. 

The  cases  showing  incomplete  division  of 
nerve  trunks  call  for  the  most  deliberate  judg- 
ment. Many  of  these  cases  recover  spon- 
taneously, though  periods  of  arrested  progress 
are  not  infrequently  most  disquieting  and 
confusing.  There  is  often,  not  actual  anatomi- 
cal interruption  of  conductivity,  but  merely  a 
physiological  one.  Differentiation  is  at  times 
exceedingly  difficult,  usually  impossible  with- 
out repeated  painstaking  examinations ;  but  as 
a  rule  in  physiological  interruption  muscle 
tone  is  more  often  preserved  than  not.  The 
lesion  in  physiological  interruption  is  fre- 
quently extra-neural  due  to  compression  by 
scar,  bone,  or  foreign  body,  without  definite 


103 

destruction  of  neurons  until  pressure  has  been 
long  maintained.  On  the  other  hand  the 
lesion  may  be  the  result  of  a  simple  contusion 
without  laceration,  causing  either  an  intra- 
neural hemorrhage  or  merely  a  localized 
edema,  both  of  which  through  compression  of 
neurons  give  rise  to  physiological  non-con- 
ductivity. All  such  intra-neural  lesions  tend 
to  recover  without  permanent  destruction  of 
nerve  fibers.  Whether  physiological  interrup- 
tion is  due  to  extra-neural  or  intra-neural 
causes  is  most  difficult  of  decision ;  and  as 
time  goes  on  decision  becomes  urgent  be- 
cause, if  extra-neural  conditions  persist,  they 
may  easily  cause  irreparable  and  permanent 
damage,  while  intra-neural  lesions  tend  to  im- 
prove spontaneously  by  absorption  of  exudate, 
and  almost  never  grow  worse.  When  in 
doubt  and  decision  presses,  it  is  always  justi- 
fiable to  cut  down  on  the  nerve  and  determine 
conditions  by  actual  inspection  which  is  a 
tolerably  safe  guide. 

Trench  Foot. 
There  has  come  out  of  the  war  a  new  dis- 
ease, trench  foot,  which  lies  somewhere  be- 
tween chilblain  and  frost-bite,  and  is  charac- 
terized by  painful  anesthesia,  edema,  phlyc- 
tenules, gangrene,  and  sloughing.  It  follows 
exposure  to  wet  and  cold,  not  necessarily 
freezing,  and  is  aggravated  by  inactivity, 
cramped  posture,  and  tight  boots.  Mild  cases 
complain  of  numbness,  cold,  pain,  and  tender- 


104 

ness  of  a  burning  tingling  character  most 
marked  at  points  of  greatest  pressure  such  as 
the  heel  and  ball  of  the  foot.  The  part  af- 
fected shows  discoloration  varying  from 
slight  hyperemia  to  purple ;  and  anesthesia  to 
touch  and  pin  prick.  Moderate  cases  have  in 
addition  severe  pain  on  exposure  to  heat  and 
on  motion  of  the  joints  in  the  affected  region. 
The  most  severe  types  show  also  blebs,  edema, 
and  local  gangrene. 

Difterential  diagnosis  is  concerned  only  with 
chilblain  and  frost-bite.  The  former  is  ac- 
companied by  intolerable  itching;  the  latter 
occurs  more  often  in  very  cold  dry  weather 
and  shows  more  massive  destruction. 

Treatment  is  prophylactic  and  symptomatic. 
Adequate  protection  from  cold  and  wet  is 
primarily  essential.  The  most  comfortable 
and  eftective  dressing  is  a  powder  composed 
of  boric  acid  and  camphor.  Whether  definite 
skin  lesions  are  present  or  not,  antitetanic 
serum  should  always  be  given  in  prophylactic 
doses.  Radical  intervention  is  strictly  ta- 
booed ;  all  that  is  required  is  patience  until 
spontaneous  separation  of  the  slough  and  nice 
demarcation  of  the  line  of  gangrene  occur, 
when  the  obviously  devitalized  tissues  may  be 
trimmed  away.  Convalescence  is  prolonged 
and  some  permanent  disability  is  not  so  very 

infrequent. 

Burns. 
There   seems   to   be   a   wide   spread  feeling 
that  the  war  has  revolutionized  the  treatment 


105 

of  burns,  which  is  entirely  erroneous.  News- 
paper exploitation  of  a  new  remedy  credited 
with  exorbitant  journalistic  virtues  is  alone 
responsible  for  the  feeling.  The  truth  of  the 
matter  is  that  the  importance  of  treating  burns 
as  aseptically  as  are  all  other  wounds  was  so 
emphasized  that  much  of  the  credit  usurped 
by  paraffine  mixtures  rightly  belongs  to  asepsis. 
Nevertheless,  there  is  much  virtue  in  these 
various  mixtures  which,  irrespective  of  other  in- 
gredients, are  essentially  parafifines  of  low  melt- 
ing point.  They  are  applied  directly  to  the 
burned  surface,  either  painted  on  with  a  camel's 
hair  brush  or  sprayed  on  from  a  special 
atomizer,  when  the  mixtures  immediately 
harden.  The  only  further  requirement  is  a  few 
layers  of  gauze.  These  parafifines  form  perfect 
protective  dressings  as  painless  in  their  removal 
as  in  their  application.  Beneath  them  fine 
healthy  granulations  rapidly  appear  with  no 
tendency  toward  exuberancy.  Epidermization  is 
swift,  and  the  terminal  scar  is  soft  and  pliable 
pleasingly  free  from  annoying  contractures.  As 
a  matter  of  fact,  however,  the  share  of  credit 
that  redounds  to  paraffine  mixtures  is  by  no 
means  exclusive ;  for  equally  as  effective,  pain- 
less, and  satisfactory  a  remedy  for  burns  is 
found  in  dichloramine  T.  Furthermore,  the 
latter  has  antiseptic  properties  that  paraffine 
mixtures  lack  which  adds  a  welcomed  sense  of 
security. 

Physio-therapy. 
Probably    never    before    has    the    value    of 


1C6 

physio-therapy    been    so    generally    appreciated. 
Men  well  versed  in  the  use  of  heat,  light,  baths, 
massage,  and  electricity  have  ably  and  conclu- 
sively  demonstrated   the   invaluable   efficacy   of 
these  agents  when  scientifically  and  persistently 
employed.     Through    their    untiring    zeal    and 
efforts  many  a  joint  has  been  spared  disability ; 
many  a  contracture  has  been  prevented ;  many 
a  nerve  has  had  its  conductivity  restored ;  and 
many  a  painful  convalescence  has  been  agree- 
ably  shortened.     No  longer   can   surgeons   dis- 
miss as  cured  fractures  whose  union  is  firm  and 
whose  soft  parts  are  healed  with  the  complacent 
remark  that  only  time  and  use  will  restore  per- 
fect function.     Far  too  often  in  the  past,  how- 
ever, function  has  never  fully  returned  because 
the  surgeon's  interest  in  the  cases  ceased  with 
anatomic  repair  and  there  was  no  one  to  super- 
vise    functional     convalescence.     Perhaps     the 
fault   does    not   lie    wholly    with    the    surgeons. 
Very   often   patients   themselves   have   been    so 
satisfied  with  anatomic  repair  and  vague  assur- 
ances  as   to   the   future,   that   they   wilfully   or 
ignorantly    forewent  prolonged   after-treatment. 
Wounded    soldiers,    on    the    other    hand,    were 
under  orders  and,  willing  or  not,  had  to  submit 
to  extended  treatment.    Doubtless  this  ability  to 
control  patients  was  a  very  essential  factor  in 
the  success  of  physio-therapy;  but  lack  of  this 
control  is  not  an  excuse,  but  merely  an  explana- 
tion of  failures  in  civil  life.    And  the  explanation 
offers    the    remedy.     Now    that    surgeons    have 
been  brought  to  appreciate  the  value  and  ncces- 


107 


sity  of  physio-therapeutic  after  care,  laymen 
must  through  a  campaign  of  education  be  like- 
wise taught  not  only  to  recognize  the  value  of 
such  measures  but  also  to  demand  that  they  be 
given  the  benefit  of  them. 


DATE  DUE 


Prifllad 
In  USA 

COLUMBIA  UNIVERSITY 


0032415311 


